Community Oral Health & Bioethics

Community Oral Health &

Bioethics5th ADEA International Women’s Leadership Conference

Barcelona, 16th September 2014

Professor Sudeshni Naidoo

Deputy Dean: Postgraduate Studies & Research

Background

• Global patterns of oral diseases continue to

reflect the widespread inequality in the access

to public preventive and dental care

• Differences in the availability, accessibility and

acceptability of education and oral health care

• Bioethics - concrete tool for the discussion,

improvement and consolidation of citizenship,

human rights and social justice

• This presentation will reflect on community oral

health in underserved populations from a

bioethical standpoint

Introduction

• Bioethical principles of Beauchamp and

Childress:

– Autonomy

– Beneficence

– Non-maleficence and

– Justice

Bioethics and Public Health

• Bioethics - an academic discipline & cultural

movement

• Socio-political, cultural and techno-scientific

developments

• In public health, it offers a multidisciplinary and

interdisciplinary approach that views humans in

their entirety (Fortes & Zoboli, 2004)

• A deeper look at the ethical conflicts of

community health and peculiarities of the

scenario in which they occur


Developing countries discussions should be embedded in the

operation of public health systems and include the following factors:

– a discussion of the social responsibility of the state,

– a definition of priorities regarding the allocation and distribution

of resources,

– a discussion of systems management,

– the organized involvement of the population throughout the

process,

– the preparation of appropriate human resources,

– a review and an update of codes of ethics for different

professional groups and

– the necessary and profound changes required in university

curricula (Garrafa, 2005).

2 Key Concepts

The bioethics of emerging situations and the bioethics of persistent

situations (Garaffa, 2005):

• The first condition treats questions that have arisen with recent

biotechnological and scientific advances

• Bioethics of persistent situations addresses issues that persist

despite the socio-economic and technological development of a

society

• Bioethics of developing countries should be concerned mainly with

persistent situations and should look ahead to a discussion of

strong interventionist bioethics. Therefore, intervention bioethics is

a proposal under construction that includes a constant, complex,

multi-faceted discourse


• Bioethics generates dynamic responses to an intense

transformation of existing reality(Cruz & Trindade, 2006)

• Advocates a prioritization of policies and decision-

making

• It urges the re-examination of certain dilemmas, such as

autonomy versus justice/equity, individual benefit versus

collective benefits, individualism versus solidarity,

participation versus omission, and temporary changes

versus permanent transformation (Garaffa & Porto, 2002)

• Its purpose is to legitimize the discussion of bioethics

from a broad perspective, which involves the social

production of disease and the effect of social inequality

in practice and health services (Porto & Garaffa, 2009)

Principle of Protection

• The state assumes the role of protecting all citizens in its

territory because they do not have the objective and

subjective means to protect themselves against certain

risks and threats to their personal integrity (vulnerability)

• Protection - a safeguard of essential needs

• Protection bioethics considers the right to health care

and the equality of treatment as the main objects of study

and focuses on devices that are capable of ensuring

these rights (Pontes & Schramm, 2007)

• Evident that bioethics and community oral health have

many points of convergence because both are concerned

with issues of human rights, citizenship, social

movements and public policy

Global Burden of Disease

• Oral diseases have a huge impact - individual as

well as collectively

• Profound impact on general health, and several

oral diseases are related to chronic diseases like

diabetes and obesity

• Dental diseases have an impact on well-being and

quality of life

• Fourth most expensive disease to treat: if

treatment were available to all, the costs of dental

caries in children alone would exceed the total

healthcare budget for children

Global Burden of Disease• Prevalence of dental caries in children has declined

markedly over the past 30 years in most countries

• Implementation of a number of public health measures

including an effective use of fluorides, changes in living

conditions and lifestyles and improved self-care practices

• But there are many disparities – the disease remains in

certain demographic groups - children, older adults and

people with poor education or low socioeconomic

status(Savage et al, 2004), racial and ethnic minority

groups and individuals with special health needs are

defined as high-risk groups (Selwitz et al, 2008)

• In essence, populations most affected – the vulnerable and

underserved - are those who receive the least care (Duffin,

2009).

Bioethical Aspects of Care

in Public Oral HealthSocial inequities and access to oral health

• Current disparities a reflection of the differences in

socio-economic development

• Inequalities affect oral health in the same manner

that they affect a wide range of health issues

• Determinants of oral health are the same for general

health and may not be strictly interpreted as a lack

of dentists, lack of health care or a poor

professional education model (Hobdell et al, 2002)

• Socio-economic inequality is the most prominent

characteristic, with severe consequences for health,

especially oral health (Evans, 2006; Dharamsi, 2006)


in Public Oral HealthSocial inequities and access to oral health

• Public health services constitute the main resource for the

majority of the underserved populations

• Access to oral health is not restricted to dental treatment;

but access to preventive measures against oral diseases

• Water fluoridation: uneven in the countries around the

world - only 35 countries covering 377m

• The philosophy and organization of the health system and

health education are also determinants of oral health

(Hobdell et al, 2002)

• From the collective point of view, the bioethical principle

of justice concerns equal access to health services for all

people, the distribution of resources and the criteria to

fairly resolve these issues.

Egalitarianism

• All persons are of inherent worth and should

have their health needs met

• Considering that each individual is a being with

needs, the maximum guideline is to attend to

each person according to his or her needs.

• Cost pressures from various factors result in

changes and reforms that require broad ethical

reflection on the prioritization and limitations

of the distribution of health resources


in Public Oral HealthFinancial Resources

Poor conditions of life (which have a major impact

on levels of health)

Budgetary and management difficulties of

countries public administrations (Narvai, 2006)

The provision of oral health care remains

hampered by factors related to the financing of

these activities and services(Moimaz et al, 2008)

Scenarios create constraints for access to oral

health services, suffer from limitations in the

nature of their actions (Pires & Cerveira, 2003)

Dental Professional Training

• Dental professional training - often inappropriate

for the desired profile of the public health system

• Inadequate in meeting the health needs of the

population - and has a direct influence on the

quality and effectiveness of the health system

(Martins et al, 2009;Amorim et al, 2009)

• Lack of reflection by university leaders in

everyday teaching and practice - indifference

regarding social injustice – with no clear social

and ethical responsibilities

• Focus on a certain level of responsibility and

technical commitment


• Need for the transmission of humanistic values at the

university level (Schuh et al, 2009)

• Professional socialization - incorporation of professional

morality

• In the health field, the teaching of ethics lags behind the

needs of society

• The teaching of bioethics in graduate courses constitutes

a framework that allows for reflection and a critical view of

the world by focusing attention on the social, cultural and

economic problems of a population

• It should stimulate the social commitment to improving

people’s quality of life, especially in the sphere of

professional actions (Prado & Garaffa, 2006)


Concern that students and trainees from different

specialties do not receive the same level of education in

the scientific, technical and ethical fields (Francesconi &

Goldim, 2005)

The 21st century needs a new paradigm in which health

professionals receive the same proficiency in all three

areas simultaneously and have the ability to exercise their

expertise in different social realities

The people who are responsible for education in the health

field should endeavour to put the concept of the

indivisibility of the three compartments into practice

resulting in more complete clinical practice

Professional Practice Model

• Good health requires good oral health, yet for example in

America alone, millions lack access to basic oral health

care. In 2008, 4.6 million children – 1 out of every 16 in the

US – did not receive dental care because their families

could not afford it.

• Lack of access to oral health care contributes to profound

and enduring oral health disparities.

• Access is hampered by a variety of social, cultural,

structural and geographic factors and there are various

opportunities in both the private and public sectors to

reduce the barriers to care.

• Overall goals of oral health care to be implemented to

underserved populations remain unclear.


• The design of a practice that is focused on the dental care

of the individual patient and performed exclusively by an

individual in a restricted surgical clinical environment has

prevailed in the private sector and exerts a powerful

influence on public services

• The development of health promotion activities at the

collective level occurs mostly in the area of health care or

schools with little use of other social spaces in the

community

• Little regularity in the implementation of these actions

• Dentists do not use risk criteria to establish the direction

of activities


• Any proposed health care interventions should take the

reality of each social context into account to understand

the individual, the citizen and the social networks that

have been built.

• These interventions are positive - emphasis on the

enhancement of collective oral health quality.

• A major challenge - involves a transformation of the

organizational form of oral health practices from a

paternalistic model of care to one that emphasizes co-

responsibility and is participatory and democratic.

• Human dignity is the core of fundamental human rights,

and its recognition as the foundation of the state. Even

sick people maintain their fundamental rights and

citizenship.

What kind of care do we

owe?

• On the fair equality of opportunity view, meeting the oral health needs

of all persons, viewed as free and equal citizens, is of comparable and

special moral importance

• Meeting oral health needs protects the range of opportunities people

can exercise, therefore any social obligations we have to protect

opportunity imply obligations to protect and promote the oral health

(normal functioning) for all people

• Various recent theories of justice affirm that we have such social

obligations to protect opportunity, and so they converge on the

importance of protecting oral health and health in general

• Justice requires that we protect people's shares of the normal

opportunity range by treating illness when it occurs, by reducing the

risk of disease and disability before they occur, and by distributing

those risks equitably

What kind of care do we

owe?

• Within the dental milieu - give all people access to a

reasonable array of services that promote and restore

normal functioning and not neglect preventive measures in

favour of curative ones

• It means we must look beyond the dental system to

traditional public health measures that profoundly affect

oral disease risk levels and their distribution

• We must also look beyond the health sector to the broader

social determinants of health and their distribution

• Since we cannot meet all the oral health needs that arise

inside or outside the dental sector, we must be accountable

for the reasonableness of the resource allocation decisions

we make

Some strategiesDental Caries, a Chronic Disease

In 2002, the WHO’s Global Oral Health Programme

was reoriented according to a new strategy:

dental caries was included in chronic disease

prevention and general health promotion

Common risk factor approach - a new public

health strategy for prevention of oral disease

Essential to change common risk factors to oral

health and chronic diseases, particularly dietary,

nutritional and many socio- environmental factors

that are distal causes of oral diseases

Some strategiesHealth Education

Health education as a social practice aimed at the

collective and other preventive measures, represent

important opportunities to expand operations in the

practice of oral health promotion in public spaces

Must be based on sound educational programmes to be

successful

We should be clear about the kinds of care we owe people

and how we determine what care is owed

We should also be clear about what constitutes

appropriate access to that care, given that there are

diverse barriers to access (Jorge et al, 2007)

All health professionals have a duty to take care of the

people under their care (Nunes, 2006)

Some strategiesTherapeutic Patient Education & Vulnerable

Populations

• Necessary to find other strategies to decrease the

incidence and burden of oral diseases

• By defining dental caries as a chronic disease and the

necessity for life-long management - the concept of TPE

for underprivileged groups can be developed to reduce the

burden and gravity of oral diseases

• TPE is meant to train patients to self-manage or adapt to

treatments and cope with new processes and skills

(Trentesaux et al, 2014)

• Community Dental Health Coordinators (CDHC) deliver

oral health education and prevention services and helps

patients to navigate an often daunting public health

system to receive care from dentists

Ethical Aspects of TPE

• Therapeutic Patient Education requires a patient to change

his identity to meet a medical ideal. This change raises

many ethical questions

• Usurp the patient’s choice by assuming someone else’s

goal (societal and or provider), or to deprive the patient of

the knowledge and skills necessary to exercise his choice

(Redman, 2008)

• Objective get patients accustomed to act as co-decision-

makers, thereby granting them highly desired

autonomy(Adewumi et al, 2001)

• Every practice that targets a clearly defined population is

bound to raise questions and create tensions. What criteria

will be used to select those who will take part in therapeutic

programmes? How can we justify these criteria?


Objective will not be to impose health standards or to

normalise behaviours but to develop the competences of

this high-risk population in order to come back to a good

oral health state

Question of the training of dentists who are primarily

caregivers and not education specialists

Dentists must be trained to educate their patient so they

may manage the treatment of their condition and prevent

avoidable complications.

Giving education its right place in dentistry means shifting

to a new paradigm by switching from a treatment-based

culture where treatment costs are supported by social

agencies, to a culture of prevention (Trentesaux et al, 2014)


Reflection is essential when implementing

therapeutic education programmes in dentistry

and more particularly in paediatric dentistry

This reflection must include a more precise

definition of the notions of information, consent,

and autonomy - will empower the patient and

enable him/her to accept or refuse to take part in

such programmes

Do not forget the triangular relationship between

the child, its parents and the practitioner -

although complex, it is essential to take this

triadic relationship into consideration

Concluding Remarks

• Consideration of the epidemiological situation of oral health

in the world especially in underserved populations

• Several aspects that directly influence a population’s

access to public dental services and actions that contribute

to inequities in oral health

• These aspects are questions of ethical content and can be

examined from ethical standpoints, especially protection

and intervention bioethics

• Health authorities are responsible for the reasonable and

effective well-being of the population by ensuring access to

health services and other health programs

• Protective responsibility - control of the outcome of

adopted policies and the evaluation of the performance of

institutions and their employees

Concluding Remarks

• Responsibility not restricted to the state and its representatives.

• Principles must be taken into account to expand, know, understand,

and establish responsibility links with the community

• Justice and social inclusion as essential elements for effective

citizenship. Health is synonymous with citizenship

• Justice is applied when health professionals use epidemiology and

social risk criteria to detect vulnerable individuals especially those in

underserved areas and facilitate their access to oral health care

• Bioethics must be taught effectively and practiced in our dental

schools. It is necessary that bioethical values, such as dignity, human

rights, respect for autonomy and vulnerability, are discussed and

incorporated into academic practice

Selected References

• Benatar S, Brock G eds. Global Health and Global Health Ethics. Cambridge University Press, 2011

• Fortes PA, Zoboli EL. Bioética e Saúde Pública. 2ª ed. São Paulo:Edições Loyola; 2004

• Hobdell M, Sinkford J, Alexander C, Alexander D, Corbet E, Douglas C et al. Ethics, equity 20. and global

responsibilities in oral health and disease. Eur J Dent Educ 2002;6:167-78.

• Evans CA. Eliminating oral health disparities: Ethics workshop reactor comments. J Dent 21. Educ

2006;70:1180-3.

• Dharamsi S. Building moral communities? First, do no harm. J Dent Educ 2006;70:22. 1235-40.

• Narvai PC. Saúde bucal coletiva: caminhos da odontologia sanitária à bucalidade. Rev 28. Saúde Pública

2006;40:141-7.

• Trentesaux T, Delfosse C, Rousset MM, HerveC, Hamel O. Social Vulnerability in Paediatric Dentistry : An

overview of ethical : Considerations of therapeutic patient education. Cult Med Psychiatry 2014; 38: 5-12.

• Institute of Medicine. Improving access to oral health care for vulnerable and underserved populations. July

2011.

Documents

Community Oral Health & Bioethics