Türk diş hekimlerindeki günlük biyoetik ikilemlerin belirlenmesi

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Introduction
Ethics is belief and principles that determine people’s behavior. Medical ethics has recently been used
instead of medical deontology, and need of investigating the responsibilities related to medical ethics has
appeared. Lessons related to medical deontology have
been taught in medical curriculums for many years.
However, they are thought to be inadequate today.
At present owing to problems related to occupational
values appeared in medical and dentistry faculties, it
became necessary to give special attention to these
subjects. Differences between deontology and ethic,
ethic in dentistry, responsibilities of dentists, context
of ethic courses made in faculties, possible problems
related to ethic have been investigated (1).
Professionals are usually identified by their committment to provide important services to clients or consumers and by their specialized training. Professions
maintain self-regulating organizations that control
entry into occupational roles by formally certifying
that candidates have acquired the necessary knowledge and skills. The concept of a medical professional
is closely tied to a background of distinctive education and skills that patients typically lack and that
ethically must be used to benefit patients.
Health care professions typically specify and enforce obligations, thereby seeking to ensure that persons who enter into relationships with their members
will find them competent and trustworthy. The obligations that professions attempt to enforce are role
obligations that are correlative to the rights of other
persons. Problems of professional ethics usually arise
from conflicts of values, sometimes conflicts within
the profession and sometimes conflicts of professional commitments (2).
Despite the prominence of ethics in medicine there
is little collected information on dentists’ perceptions
of bioethical problems in practical settings or how
physicians feel these dilemmas affect them. Most of
* Department of Conservative Dentistry and Endodontics, Gulhane Military
Medical Academy
** Dental Service, Turkish Army Land Forces
Reprint request: Fulya Toksoy Topçu, Department of Conservative Dentistry
and Endodontics, Gulhane Military Medical Academy, Etlik-06018, Ankara,
Turkey
E-mail: fulyatoksoy@yahoo.com
Date submitted: May 27, 2009 • Date accepted: June 11, 2009142 • September 2009 • Gulhane Med J Şahinkesen et al.
the published research about this issue has focused on
the ethical dilemmas of medical students. There have
been few attempts to evaluate healthcare providers in
their respective clinical environments. Hence, the type
and frequency of bioethical dilemmas that dentists
identify are relatively unknown with a few exceptions.
There is considerably less discussion, however, of what
bioethical issues physicians actually confront, and the
impact the resulting dilemmas might have on the dentists as they adapt to the clinical world and make decisions concerning their own conduct and role (3).
This study aims to demonstrate the range of bioethical dilemmas confronted by Turkish dentists. The
study was designed to obtain descriptive baseline data
and to suggest educational and policy approaches for
dealing with the full range of bioethical problems
confronted by these dentists.
Material and Methods
This study was designed to elicit dentists’ opinions
about three issues: 1) how do Turkish dentists most often identify or recognize an ethical dilemma? 2) type
and frequency of ethical dilemmas which Turkish
dentists encounter during their day-to-day practice,
and 3) their resources utilized in resolving ethical
dilemmas. The survey instrument was a self-administered questionnaire, which was developed specifically to collect data on addressing objectives of this
study. We developed a structured questionnaire and
used it in interviewing a large cross-section of different dentists regarding the ethical problem about daily
medical practice. A structured interview schedule was
developed and pretested by a trained interviewer. To
examine test-retest reliability, 20 respondents were
interviewed twice, with a one-week interval between
interviews. At least 90% of the respondents provided
identical answers to all items on both administrations
of the test. The interview schedule was therefore considered to have an adequate test-retest reliability.
The questionnaires were given to the participants
during routine training hours and they were asked to
fill it in under observation. The data were collected
and entered into the SPSS package software for statistical analysis.
Results
One hundred and ninety one dentists working at different hospitals responded the questionnaire. Dentists
were asked to rank forty three ethical dilemmas in order of importance to their medical practice. By asking
participants to rank bioethical dilemmas relative to
each other, the survey tried to determine what dilemmas were considered “most important” in the day-today practice of the physicians. When questioned as
to whether these specific topics had presented ethical
conflicts for them “frequently”, “often”, “sometimes”,
“rarely”, or “never”, the physicians stated that ethical dilemmas regarding excessive amount of patients
(93, 27.8%), patient wronged owing to procedure and
regulation (60, 17.9%), patient wronged owing to bureaucratic reasons (57, 17.1%), insufficient condition
about patient examination and treatment (40, 11.9%)
occurred most frequently, followed by dilemmas regarding friends’ private/privilege demand about patient (36, 10.7%), prescription without examination of
patient (36, 10.7%), and colleagues’ private/privilege
demand about patient (34, 10.2%).
In solving ethical problems met by participants
solutions are classified according to their values.
Methods used in solving ethical problems and their
importance order were shown in Table I.
According to participants some solutions have
same value, so total of rates increases 100%. While
Table I was investigated among the methods, method
solving ethical problems without giving any harm to
people was found to be most effective (61.4%). But,
protecting limited resources option was assessed to
be the most ineffective by all participants. Moreover,
Table I. Values used in solving ethical problems
Values used in solving ethical problems (n) (%)
Importance sequence
1 2 3 4 5 6
By increasing happiness and goodness of patient 41 (22.0) 63 (33.9) 39 (21.0) 19 (10.2) 8 (4.3) 16 (8.6)
Not giving harm to patient 116 (61.4) 40 (21.2) 9 (4.8) 11 (5.8) 7 (3.7) 6 (3.2)
By giving importance to society and organizations’ interests 14 (7.4) 39 (20.7) 56 (29.8) 49 (26.1) 23 (12.2) 7 (3.7)
By giving importance to his/her own interests 10 (5.3) 9 (4.8) 24 (12.7) 40 (21.2) 48 (25.4) 58 (30.7)
By protecting limited resources 5 (2.7) 9 (4.8) 32 (17.0) 53 (28.2) 63 (33.5) 26 (13.9)
By taking any risk 11 (5.9) 23 (12.4) 27 (14.5) 17 (9.1) 34 (18.3) 74 (39.8)Volume 51 • Issue 3 Bioethical dilemmas • 143
solving ethical problems by increasing patient’s happiness was found to be as second effective method.
Participants were asked whether they participated
in any course on ethics or not. Answers given by participants are shown in Table II. When Table II was analyzed it was found that 32.3% of the participants did
not participate any course on ethics, and only 23.6%
of them participated private courses. It was found
that when participants’ working hour increased their
attendance to courses also increased. Only 39% of the
participants participated ethics courses during their
bachelors’ degree and only 5% of them participated
to them during their expertise training. In terms of titles it was found that practitioners participated courses more frequently than dentists.
With whom participants chose to talk on ethical
problems were classified according to their priority.
Priority of people to whom applied for ethical problems and their importance order was shown in Table
III. When Table III was analyzed according to all participants, the most popular method was “I would
want help from other colleagues” (42.4%). Other
popular methods were “I would want help from ethical committees”, “I would read regulations and directives”, “I would apply to administrators and reliable
elders”. All participants were agree not to ask ethical
problems to religious leaders.
Discussion
The majority of recent literature on bioethics
tends to focus on bioethics education (what material
should be taught, how the material should be taught,
and how it should be analyzed). There is considerably
less discussion, however, on what bioethical issues
physicians actually confront, and the impact the resulting dilemmas might have on the physicians and
their practice. As in other scientific area, there has
been a sharp increase in recent years in the variety
and complexity of ethical problems in the practice
of medicine. Therefore, this study was designed to
Table II. Number of courses that participants attended
Parameter Groups
Education related to ethics/Where did you participate the course? (n) (%)
Not participated At university At expertise training Meeting/Courses
General 71 (32.3) 86 (39.1) 11 (5.0) 52 (23.6)
Sex Female 45 (31.9) 52 (36.9) 6(4.3) 38 (27.0)
Male 71 (22.0) 64 (19.8) 110 (34.1) 78 (24.1)
Age ≤34 27 (36.5) 30 (40.5) 7 (9.5) 10 (13.5)
35-40 25 (32.5) 27(35.1) 4 (5.2) 21 (27.3)
41+ 18 (28.6) 25 (39.7) 0 (0.0) 20 (31.7)
Working duration ≤4 years 26 (39.4) 27 (40.9) 7 (10.6) 6 (9.1)
5-14 years 28 (31.1) 32 (35.6) 4 (4.4) 26 (28.9)
15+ years 18 (28.6) 25 (39.7) 0 (0.0) 20 (31.7)
Title Practitioner 45 (28.3) 72 (45.9) 0 (0.0) 41 (25.8)
Others 28 (44.4) 14 (22.2) 10 (15.9) 11 (17.5)
Table III. “With whom would you prefer to talk for solving your ethical problems?”
With whom would you prefer to talk for
solving your ethical problems? (n) (%)
Priority order
1 2 3 4 5 6 7
Professional colleague 75 (42.4) 27 (15.3) 10 (5.6) 37 (20.9) 17 (9.6) 7 (4.0) 4 (2.3)
Mentor or superior 33 (19.1) 64 (37.0) 38 (22.0) 15 (8.7) 13 (7.5) 6 (3.5) 4 (2.3)
Spouse/family member 7 (4.2) 3 (1.8) 24 (14.5) 12 (7.3) 28 (17.0) 82 (49.7) 9 (5.4)
Lawyer 9 (5.4) 14 (8.4) 33 (19.8) 41 (24.6) 47 (28.1) 21 (12.6) 2 (1.2)
Ethics committee 34 (20.2) 32 (19.0) 34 (20.2) 29 (17.3) 31 (18.5) 5 (3.0) 3 (1.8)
Regulations and directives 34 (20.0) 34 (20.0) 29 (17.1) 24 (14.1) 19 (11.2) 28 (16.5) 2 (1.2)
Religious leader 8 (5.1) 0 (0.0) 1 (0.6) 6 (3.8) 2 (1.3) 12 (7.6) 128 (81.5)144 • September 2009 • Gulhane Med J Şahinkesen et al.
extend current knowledge about ethical dilemmas in
the healthcare and to identify reoccurring ethical issues and themes in the practice (4).
Ethical dilemmas may perplex physicians because
strong reasons for a course of action may be balanced
by powerful countervailing arguments. Common
sense, clinical experience, being a good person, and
having a good intention may not guarantee that physicians will know how to respond appropriately to
such dilemmas. Ethical dilemmas provoke powerful
emotional response, and strong emotions often are
a clue to the presence of an unresolved ethical issue.
However, emotions alone are not a satisfactory way
of resolving ethical dilemmas (5).
Ethical processing can be seen as having several
components: to learn to recognize bioethical dilemmas; to “unpack” the dilemma and thoughtfully
consider the issues and people involved; to become
attuned to one’s own rationales and motives, noble
and otherwise; to develop a flexible framework with
which to address and ideally resolve bioethical issues
with patients and colleagues of varying seniority; and
to establish a personal ethic appropriate to one’s role
on the medical team (6).
Although 23.6% of participants attended courses
on ethics, the quality and quantity of this education
is not clear enough. Thus, courses on ethics should
be developed by Dentistry Unit, and standardization
should be achieved. Moreover, all graduated-dentists
must be obliged to participate these courses at regular
intervals.
When participants came up with ethical problems they wanted help firstly from their colleagues,
and secondly from ethic committees. But by means
of courses on ethic dentists’ knowledge can be improved and their belief in ethic committees can be
increased.
Previously there was no system in place to adequately identify the type of bioethical problems
being confronted by Turkish physicians working in
different medical field, nor the frequency in which
the dilemmas are occurring. This lack of research
had produced a knowledge gap concerning whether
medicine providers in the healthcare system readily identify and deal with bioethical dilemmas. This
study attempted to help narrow this knowledge gap
and provide educators with some initial findings on
what bioethical dilemmas are being faced and how
frequently. We conclude that most of ethical dilemmas are caused by dentists lack of knowledge on this
subject. There is a need for increased ethics education
among Turkish dentists.