Dr. Moshe Kelman
Director of Dental Health, Ministry of Health
Ethical Standards in Dentistry
As of July 1993 there are 6,210 licensed dentists in Israel. 1,712 (38%) immigrated in the last three years, mostly from Eastern Europe. Israel has dentists from 52 countries; more than 53% from Eastern Europe; less than 20% were trained in Israel. In Western countries there are far fewer dentists relative to the total population and the vast majority were trained in their country of residence.
Ethics is not a fixed code of behavior. It is affected by many factors including demography, geography, economy, sociology, history and even politics. Ethical codes are dynamic and determined by the professional community. That which was acceptable one hundred years ago is often unacceptable today. That which was not permissible fifty years ago has often become the norm. There are developed and respected jurisdictions where a physician may openly advertise himself, and there are countries, among them Israel, where every form of advertising is forbidden.
In some countries complicated or dangerous procedures are limited to specific institutions or specialists. However, in other countries every licensed physician is permitted to perform any procedure and is trusted not to carry out any treatment in which he is not competent. It is of interest that in
Israel there are restrictions on certain procedures in medicine, not merely heart transplants but also quite simple treatments. In dentistry, however there are as yet no restrictions whatsoever, and a dentist may carry out any treatment that he wishes. Strong pressures exist to restrict certain procedures and conscious sedation and implantology, for example, will probably be limited to those with specific training.
Sadly, a number of complaints of sexual harassment in dental offices have been received. Only two years ago the ministry canceled the license of Israel Dagan for homosexual abuse of children whom he had treated.
The standard defense in such cases is that the allegation is an attempt at blackmail or is the result of sexual fantasy of the patient. In no case examined, was there a chairside assistant present during the alleged assault. There is much justification for the halachic prohibition of yichud (the sole presence of a man with an unrelated female adult in the same room), and there is a case for mandating the presence of a third party in the clinic setting.
"A hungry dentist is a dangerous dentist," says Prof. Aubrey Sheiham from London. The large number of physicians and dentists in Israel increases the dangers of unnecessary treatment. Since over 70% of dentists work in the private sector and nearly 10% in the commercial sector, this danger is very real. With the increase in living standards and reduction in the incidence of dental disease during the past ten years, more and more people are presenting for cosmetic dentistry. In many cases cosmetic treatment may well be considered essential dental care. Treatments which do not add to the health of the patient, however, border on charlatanism.
There is a tendency among young dentists to enter into "prestigious" areas of practice without appropriate training. There is little doubt that today many dentists insert implants without the required skills. There cannot be "informed consent" for treatment when the dentist has "forgotten" to tell the patient that he lacks the training to perform the treatment to the highest possible standard.
The limit to the information that the dentist must give to his patient is set by the intellectual ability of the patient to absorb such information. A signature will not serve as a defense in court when there is a clear contraindication to the treatment proposed.
In implantology it is normal practice for the patient to sign a clause explaining that an implant may be tissue-rejected, and in such a case the dentist is not liable and the patient has to pay for a second treatment. Not every implant failure is due to tissue rejection and the patient cannot waive his basic rights by signing a "carte blanche" consent form, or even the standard consent form used in the most prestigious of medical centers.
The welfare of the patient is paramount and the dentist must remember "FIRST - DO NO HARM."