Morality and decency

The public has a high expectation of the moral standards that should be maintained by anyone who employs a position of trust in society.

Morals are essentially guiding principles in relation to what is right and wrong, and they can apply to all kinds of behaviour. Moral actions and behaviour are virtuous, respectable and beyond reproach, so they clearly form an integral part of ethics.

The converse terms 'immoral' or 'immorality' are, however, most often used to describe sexual misdemeanours, although this is actually only one aspect of immorality. The terms 'indecent' and 'indecency' have been similarly commandeered to signify something improper or obscene in a sexual sense, whereas 'decency' is essentially the quality of fairness, respectability and of upright and proper behaviour.

Another important facet of morality relates to honesty, but this is discussed separately, at length, in a separate module within this series (Ethics module 6).

It is obvious that a dentist should avoid any situation where it might be suggested that s/he has acted in an immoral or indecent fashion in relation to a patient. Less obvious, perhaps, is the fact that the dentist: patient relationship is by no means the only area where questions of morality and/or decency might arise, that could impact upon a dentist's professional career.

Regulatory bodies (Dental Councils and Dental Boards) have been known to view with equal concern, allegations of inappropriate behaviour, especially of a sexual nature, involving staff members or even situations arising in a dentist's personal life. The basis for this is that such behaviour can still suggest what is sometimes described as 'moral turpitude' “ that is, deficiencies in a person's moral standards “ whether or not any patients are involved. There is also a potential for such behaviour to impact upon the reputation of the profession, to discredit it in the eyes of the public, or to undermine public trust and confidence in the profession.

Thus, allegations or convictions for indecent assault, or those which involve offensive behaviour of a sexual or immoral nature, or rape (for example) or pornography (especially child pornography) are likely to be viewed with great seriousness.

Serious criminal offences aside, some might question what relevance some of these other offences could possibly have to one's ability to practise dentistry, and ask why a dentist is not entitled to a personal/private life like anyone else in society.

Such views are understandable, but regulatory bodies exist to protect the public, and in doing this, certain values and standards of personal behaviour are generally expected and considered to be a pre-requisite for the relationship of trust and confidence that needs to exist between any healthcare provider, and a patient.

It is the abuse of this trust that lies at the heart of cases where acts of immorality and indecency, end up placing a dentist's professional career at risk. The higher the public's expectation of morality and decency, the more severe any disciplinary sanction is likely to be. Here again, as in many other areas, we find that the price of being a member of a respected profession is high.

Misunderstandings

Dentists are regularly placed in very close physical proximity to patients, which creates a need for dentists to be mindful of how their actions may be perceived or interpreted, however innocent or well-intentioned they might be.

When dealing with a patient who is acutely anxious or distressed, it is a natural human reaction to help and support them, and to demonstrate care, concern and compassion. In some healthcare settings “ such as when someone is being told that a close relative has died “ this may well involve putting a reassuring arm around them, or touching/holding their hand. In the past, such acts on the part of a healthcare professional would rarely have raised any doubt or concerns, but the world is changing and one can find the most natural and innocent gestures being questioned.

Some individuals are instinctively tactile in their interpersonal communication, and because this is their natural style, it may not even cross their mind that it could be unwise to adopt this same approach when dealing with patients. Much depends upon the context, of course, and factors such as the age/sex/previous relationship of the parties are obviously relevant. But past experience suggests that male dentists need to be particularly cautious about any physical (touching) contact with female patients, however innocent or well-intentioned the motive.

Something which might be acceptable in the context of a longstanding relationship of trust and confidence between a patient and dentist, built up over many years, may be more problematic and likely to be misinterpreted if the same events were to take place at a patient's first visit.

Just as dentists are different, so also will wide variations be encountered from one patient to another, because of their own background, upbringing and personal communication style.
There are also important cultural variations to bear in mind. A reassuring and fleeting touch of the arm of one person may be welcomed, while another patient may find such a gesture quite alarming and offensive.

Whether patients are being treated in the supine or seated position, different situations can arise which leave a dentist vulnerable to allegations of inappropriate touching of a patient, or violating the patient's modesty in terms of alleged voyeurism.

Practitioners deal with the latter problem in a variety of different ways, including the use of bibs/aprons/protective drapes to cover the patient's chest, and/or blankets to cover the legs of female patients, and so on.

But great care should be taken by male dentists when instruments/materials are being passed across a patient's chest to or from a dental assistant or similarly, when any procedure is being undertaken which might bring the dentist's arm or elbow across the patient's chest.

It goes without saying that where dentists are found to have committed acts of indecency, or to have behaved immorally, this produces such a fundamental breach of trust that the professional consequences are likely to be severe. The maintenance of public confidence in the profession dictates that the strongest signs of disapproval will be conveyed by regulatory bodies. Their intention is also to remind dentists how serious offences of this nature are treated, because their nature is so contrary to the high ethical standards to which the profession aspires.

Chaperonage

It is generally unwise for a dentist to treat any patient without a third party being present. In general, the third party should be appropriately trained to assist the dentist in an emergency situation, but if the patient happens to be of the opposite sex to the dentist, this third party can also fulfil a second useful role as a chaperone This will often be a dental nurse/assistant, but it could equally well be a parent/family member or other third party who is accompanying the patient.

It should be realised that neither provides absolute protection against allegations that inappropriate things were said or done; such allegations have in the past related to acts which are said to have occurred:

• When a nurse/assistant leaves the surgery, even briefly.
• When a nurse/assistant's back is turned or when he/she is occupied with other activities.
• When the third party happens not to be observing what is happening.

Dentists will sometimes find themselves seeing patients when no one else is present on the premises at all “ perhaps in an out of hours emergency situation, or when treating a patient in a domiciliary or other non-surgery setting. While every effort should be made to avoid these situations, the patient's needs and interests should always be the clinician's primary consideration (subject to any safety considerations that might be necessary).

Sedation

A striking number of allegations of sexual assault or inappropriate sexual behaviour arise in connection with the administration of general anaesthetics or sedation. Here, it is absolutely essential (for reasons of patient safety, as well as chaperonage) that a dentist is never left alone with an unconscious or sedated patient.

Some drugs have been shown to have a propensity to lead to hallucinatory experiences, often of a sexual nature, in some patients. This can result in a patient's very vivid 'recollection' and descriptions of events both during treatment and during the immediate postoperative recovery phase, which can be shown with certainty not to have occurred at all.

But the risk of such allegations is ever-present and dentists need not only to ensure that their actions are above reproach, but also to make appropriate arrangements to ensure that they can demonstrate this to be so.

Of particular concern in cases which involve allegations of indecency, is any suggestion that a dentist might have contrived a situation where s/he would be left alone with a patient, however briefly, and/or had designed a means by which any inappropriate behaviour would not be discovered. Taking advantage of a sedated or unconscious patient is one example of this. This topic is considered in greater detail in the module on Sedation (number 17) in Dental Protection's series of risk management modules.

Employment

Acts of impropriety and indecency do not necessarily need to involve patients, in order to cause problems for dentists. Allegations of sexual harassment can also raise concerns about a dentist's ethical and moral standards. At one extreme is the employer who indecently assaults a member of staff, at the other is a workplace culture in which comments or suggestions of a sexual nature are regularly made. Not all employees feel able to voice their objections to such comments, however offended they might feel. Some employers will mistakenly conclude from this silence, that the comments are acceptable or even welcome.

Some previous cases have involved such persistent or extreme sexual harassment that the events have attracted the attention of the Dental Board/Dental Council “ perhaps because the employee in question made a specific complaint, or perhaps as a result of a adverse finding by an employment Tribunal, or a conviction, or occasionally, simply because of the associated media coverage.

Dentists, whether practice owners or not, often find themselves in a position where young people join their dental team, and the dentist holds a position of responsibility or seniority over them. Any attempt to take advantage of such a relationship, will inevitably raise questions about a dentist's morality and decency, and integrity.

Relationships

It is, of course, not necessarily unethical for dentists to form a personal relationship with an employee or working colleague. It may become so if the relationship interferes with or comprises the treatment of patients, or if the relationship is conducted in a way which might lower the reputation of the profession in the eyes of the public. In short, there should be clear separation between the professional relationship, and the personal relationship.

Personal relationships with patients are slightly different, and the issue here is that of whether any breach of trust or abuse of the dentist: patient relationship is involved.

Where a dentist enters into a personal relationship with either an employee, or a patient, where both parties are happy with the arrangements and are entering into them freely, problems are unlikely.

Allegations of impropriety are more likely if and when the relationship deteriorates, and the 'partner' in the relationship reverts to being a patient (or former patient), or an employee (or former employee). Patients have the same rights of confidentiality and of standards of care etc and employees have the same employment rights and protections, whatever the status of their relationship with the dentist. Here, the need for the clearest possible separation between the professional and personal relationships is selfevident.

An alternative scenario is seen when someone who is already in a personal relationship with the dentist, subsequently becomes a patient “ but the principles are precisely the same. The dentist's behaviour within the professional relationship must be the same as for any other patient; what happens within the personal relationship is a different matter.

Personal behaviour

Shortfalls in the standards of morality and decency in a dentist's personal life can raise concerns about their integrity as a member of a profession that enjoys a position of particular trust, given the close proximity to patients that is almost inevitable when clinical treatment is being provided.

Dentists have in the past been challenged in relation to issues in their personal life such as:

• Sexual offences and allegations of a sexual nature in relation to family members, children and other vulnerable persons.
• Lewd or offensive behaviour (such as indecent exposure).
• Use of pornographic websites.
• Possession or dissemination of pornographic or offensive material, especially where images of children are involved.

Consideration for others

Dentists, as members of a caring profession, are expected to demonstrate a high level of regard for the welfare of other members of society. It would be immoral, for example, to be involved in any act or omission that showed or suggested a disregard for others “ particularly, vulnerable or disadvantaged members of society.

Acts of selfishness, or a serious lack of care and concern for others, will inevitably raise concerns that the person may not be fit to discharge the responsibilities of a member of a caring profession such as dentistry.

Respectability and dignity

Dentists should avoid saying or doing anything that might be viewed as reprehensible. A professional person requires a sense of responsibility and a degree of self control that tells him/her where a line needs to be drawn in terms of personal behaviour. Decency is an important facet of professional integrity, and maintaining the reputation of the profession in the eyes of the public.

Summary

In this module we have attempted to explore at least some of the key issues of morality and decency expected in professional and personal life.

In most cases, people join the qualified ranks of the dental profession as young adults, and it can be a steep learning curve to appreciate the burden of expectation which is placed on their shoulders by the public, by their professional colleagues and by Dental Boards and Dental Councils.

As we saw in some of the definitions that began this module, a career as a dentist involves rather more than a 'job'. Behaviour which might be the norm in some walks of life can be viewed seriously by a regulatory body in a healthcare field such as dentistry.

The question for a Dental Board or Dental Council - and for the public - is that of whether the healthcare professional can be relied upon to be upstanding, honourable and trustworthy. The level of decency and morality displayed in your personal life, and in the broader aspects of professional and business dealings, is a pointer to the way you might behave in relation to patients in your care.

In the area of morality and decency there are no half measures for the healthcare professional.