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I am a new dentist working as a contract employee for a busy, established practice. My employer is the only other dentist in the practice. During my first few months here, I have seen my employer delegate hygiene duties, including scaling and prophylaxis, to the dental assistants. I believe that this is beyond the scope of practice for dental assistants in my state. I am required to perform the hygiene checks on these patients, and I am concerned about my legal liabilities and the ethical considerations. I cannot afford to lose this job, and therefore I am hesitant about approaching my employer about this issue. Where do I go from here?
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Unfortunately, this situation occurs with some frequency. Dental assistants with no formal hygiene training or credentials sometimes receive in-office training to perform hygiene duties that are legally and ethically beyond their scope of practice. The legal ramifications, of course, vary from state to state, and you should consult with a local attorney to ascertain the legal issues inherent in the situation you have described. Generally speaking, in the scenario you have described, state boards of dentistry might bring disciplinary action against the employer, the employee dentist and/or the dental assistant. The fact that the employees were acting on an order from the employer probably would be no defense to any charges. Furthermore, each dentist and the dental assistant may be susceptible to a civil malpractice action by a patient.
The ADA Principles of Ethics and Code of Professional Conduct1 (ADA Code) addresses your problem in several sections. Section 2, Principle: Nonmaleficence, states, "This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist’s primary obligations include ... knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate."1
Furthermore, Section 2.C., Use of Auxiliary Personnel, states, "Dentists shall be obliged to protect the health of their patients by only assigning to qualified auxiliaries those duties which can be legally delegated. Dentists shall be further obliged to prescribe and supervise the patient care provided by all auxiliary personnel working under their direction."1
It is quite clear from these sections that your employer has overstepped the ethical boundaries of the ADA Code by delegating duties to dental assistants that are beyond their scope of practice. By complying with your employer’s direction, you also are in violation of the ADA Code.
Another section of the ADA Code that addresses aspects of your dilemma is Section 3, Principle: Beneficence ("do good"):
The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient. ... [C]ontract obligations do not excuse dentists from their ethical duty to put the patient’s welfare first.1
Your employer, perhaps in an attempt to save money, is subjugating the welfare of his or her patients by allowing a lower-paid auxiliary staff member to perform hygiene duties. Again, the contract with your employer provides no defense for your complicity.
Another applicable principle of the ADA Code is Section 5, Veracity ("truthfulness"):
This principle expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people. Under this principle, the dentist’s primary obligations include respecting the position of trust inherent in the dentist-patient relationship, communicating truthfully and without deception, and maintaining intellectual integrity.1
Moreover, Section 5.A., Representation of Care, states, "Dentists shall not represent the care being rendered to their patients in a false or misleading manner."1 Both your employer and you are abusing the trust of your patients and misrepresenting the quality of care rendered to patients by allowing them to believe that the dental assistants have been properly trained and are qualified to provide hygiene services.
So what are you to do? You need to establish yourself in the profession and cannot afford to lose this job. But as a dental professional, your solemn obligation is the welfare of the patients entrusted to your care.
The introduction to the ADA Code states as follows:
The dental profession holds a special position of trust within society. As a consequence, society affords the profession certain privileges that are not available to members of the public-at-large. In return, the profession makes a commitment to society that its members will adhere to high ethical standards of conduct.1
Fortunately, your conscience is bothering you about the unethical practices that are occurring in the office. Adherence to the principles stated in the ADA Code clearly is a core value for you.
First of all, you have a duty to discuss with your employer the ethical implications of his or her practice, explaining the several ways in which delegating hygiene duties to inadequately trained staff members not only violates our ethical standards but also places both of you in jeopardy for disciplinary and civil action. Hopefully, after having understood his or her ethical obligations and being reminded of the consequences of his or her behavior, your employer will discontinue this practice and commit to professional conduct that adheres to our principles of ethics.
However, if this practice continues, you should consult with an attorney about whether you are obligated to report the conduct in question to your state board. Also, and in accord with the ADA Code, Part IV, consider bringing the matter to the attention of the appropriate state dental society. Finally, you may wish to terminate your employment and seek work elsewhere.
The vast majority of our colleagues are ethical professionals. You must take the high road here. Remember, ethical behavior is doing the right thing when no one else is looking. Let that be the mantra for your professional life, as well as for your personal life.
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