Awareness and Perception towards Dental Ethics and Ethical Dilemmas among Dental Professionals -A Cross-Sectional Study

Dentists are one among the medical professionals who often encounter complex ethical issues. Playing the role of a health professional, business enterpriser and academician they often run into speci(cid:976)ic and con(cid:976)licting ethical demands in practice and research. This cross-sectional study was conducted among dental professionals attached to educational institutions and private practitioners. A total of 95 participants, including private practitioners, faculty members, and post-graduate students, were recruited. A pre-validated, questionnaire containing questions related to awareness and perception in dental ethics was administered. Descriptive statistics was done to report the level of awareness and perception of dental professionals. About 65% of post-graduate professionals had awareness in clinical ethics when compared to undergraduate professionals who had 58% awareness. However, 75% of undergraduate professionals had awareness in research ethics compared to post-graduate professionals with 70% awareness. There was no difference in the perception level among graduate and post-graduate professionals. The awareness of dental ethics varied among dental professionals. There is a need to introduce speci(cid:976)ic continuing dental educational (CDE) programs to promote knowledge on dental ethics and dental jurisprudence to save dentist and their patients from encountering uneventful situations.

A Dentists are one among the medical professionals who often encounter complex ethical issues. Playing the role of a health professional, business enterpriser and academician they often run into speci ic and con licting ethical demands in practice and research. This cross-sectional study was conducted among dental professionals attached to educational institutions and private practitioners. A total of 95 participants, including private practitioners, faculty members, and post-graduate students, were recruited. A pre-validated, questionnaire containing questions related to awareness and perception in dental ethics was administered. Descriptive statistics was done to report the level of awareness and perception of dental professionals. About 65% of post-graduate professionals had awareness in clinical ethics when compared to undergraduate professionals who had 58% awareness. However, 75% of undergraduate professionals had awareness in research ethics compared to post-graduate professionals with 70% awareness. There was no difference in the perception level among graduate and post-graduate professionals. The awareness of dental ethics varied among dental professionals. There is a need to introduce speci ic continuing dental educational (CDE) programs to promote knowledge on dental ethics and dental jurisprudence to save dentist and their patients from encountering uneventful situations.

INTRODUCTION
The word "ethics" is derived from the Greek word "ethos", which means character or conduct (Meese et al., 2010). It is often interchangeably used with the word "moral". Ethics is an unwritten code of conduct that encompasses both professional conduct and judgement. Ethics helps to support autonomy and self-determination and to protect the vulnerable, and promote welfare and equality of human beings. Dental ethics involves moral duties and obligations of dentists towards their patients, professional colleagues and society (Humphris, 2003). Now a day's dentists face more complex ethical issues than those faced earlier. Being a health professional, business enterpriser and academician they often encounter speci ic and con licting ethical demands in practice and research. On avoiding professional paternalism, today dental professionals are confronted with ethical dilemmas in making a decision on best treatment options and respecting the choice of treatment of the patient (Beemster-boer, 2016).
A dilemma is a complex situation necessitating a choice between two equally undesirable alternatives which arise from fundamental con licts among ethical beliefs, duties, principles and theories (Mitchell, 1990). It is an apparent mental conlict between moral imperatives, which means obeying one would result in transgressing another. Since moral philosophy paradox plays an essential role in debates on ethics, an ethical dilemma can also be called as an ethical paradox (Beemsterboer, 2016;Porter and Grey, 2002). As dentist often faces situations with varied ethical considerations and complexities, ethical dilemmas can be part of dental science (Ozar and Sokol, 2017).
Due to the development and growing use of advanced technology with greater complexity in dental practice, there is a need to address and educate dental students and dental health professionals on clinical ethical values (Acharya, 2005). Also, the scope for oral health research is augmenting every day among faculties, undergraduate and postgraduate students in a ist full of dental institutions. Thus limelight on ethical research values should also be placed. Concerns among research observers arise as there is no improvement in the individual and institutional research ethics capacities and capabilities in developing countries (Deolia et al., 2014). Ethical dilemmas in research converge on three topics such as protection of human study participants, conduct and management of research, including con lict of interest; and investigator integrity (Ellen and Singleton, 2008). Thus to assess the awareness and perception of dental professionals towards clinical and research ethical principles, the present study was contemplated to include dental practitioners, academicians, and post-graduate students.

MATERIALS AND METHODS
A cross-sectional study was conducted among various dental colleges and private practitioners in Chennai from August 2019 to February 2020. This study was executed after obtaining ethical clearance from the institutional review board of Saveetha Dental College and Hospital, Chennai.
A total of 95 subjects, including private practitioners, faculty members, and post-graduate students from four dental institutions in Chennai were recruited using a non-probability purposive sampling method. The list of the private practitioner with their contact details had been obtained from Indian Dental Association (IDA); Madras branch. Prior permission and voluntary informed consent from the institutions and the participants were obtained after explaining the purpose of the study. A self-developed, self-administered questionnaire containing close-ended questions was given. The questionnaire contained ten questions, with eight clinical and two research ethical scenarios. This questionnaire was subjected to validation among dental public health stalwarts for face, content and constructs validity. The kappa value obtained was 0.77, which represents a good agreement between them. On fabricating a few corrections suggested by the stalwarts, the questionnaire was then implemented to the study participants. As an overview of the ethical principles, the questionnaire contained a brief explanation of each principle in the beginning. The ten scenarios with their accompanying questions were presented in Appendix ??. The questionnaire had two parts. The irst part contained socio-demographic information of the participants such as their level of education, the institution and department to which they belonged, and the duration of their practice.
In comparison, ten sets of clinical and research scenarios and questions were included in the second part to assess the attitude and perception of participants towards ethics. The average time taken by the participants to complete the questionnaire was 15 minutes. Descriptive statistics in terms of frequency distribution was calculated and presented in tables. Table 1 shows the socio-demographic details of the study participants. Most of the participants (62.1%) belonged to 20-30 years age group. Females (70.5%) participated more when compared to males. About 69.5% of the participants have completed post-graduation (MDS). Most of them (67.4%) played a dual role as an academician and clinician. About 57.5% of the participants were young graduates with ≤ ive years of experience.

RESULTS AND DISCUSSION
In Table 2, for scenario 1, 71.2% post-graduates and 65.5% undergraduates answered correctly. About 57.6% post-graduates and 51.7% undergraduates answered correctly for scenario 2. Similarly, for scenario 3, the correct ethical principle was opted by 65.2% and 62.7% post-graduates and undergraduates, respectively. For clinical scenario 4, about 56.1% of post graduates and 48.2% undergraduates answered correctly. Among the participants, 44.8% undergraduates and 37.8% post graduates opted correctly for scenario 5. The correct answer for scenario six was given by 72.7% post-graduates and 65.5% under-graduate participants. About 63.3% post-graduated and 51.7% under-graduated opted    Table 3 shows the attitude of participants towards research ethics. The correct ethical principle for scenario nine was provided by 63.6% post-graduated and 82.7% of under-graduated participants. For scenario 10; 56.1% post-graduated and 58.6% under-graduated opted correctly. Table 4 shows the perception of the participants towards the ethical principles for the same clinical and research scenarios. There found to be no difference in the perception for above-stated scenarios among under graduated and post-graduate professionals. They all perceived that the dentist had done unethical practice in those scenarios. The answer NO for scenario 9 was provided by 81.8% post-graduated and 75.9% of undergraduated participants. For scenario 10; 92.4% post-graduated and 96.6% under-graduated opted correctly. There found to be almost no difference in the perception for above-stated scenarios among under graduated and post-graduated professionals except for scenario 5 and scenario 9, wherein for scenario 5 most undergraduates found that what the dentist did was wrong. In contrast, for scenario 9, the majority was among post graduates who found what the dentist did was wrong.
The day-to-day decisions made by dental professionals in practice have a signi icant in luence on the oral health of the population. New codes of practice direct dentists to provide patients with all the necessary information and to offer them guid-ance so that they can select the appropriate treatment. This study was conducted to assess the awareness and perception of dental professionals in clinical and research ethics. For the eight clinical scenarios provided, post-graduated participants chose correct ethical principles compared to under graduated participants. This implies that post-graduate dentists are more informed and aware of the ethical principles than under-graduated dentists. Since most of the participants were young practitioners and academicians, and awareness towards ethical principles have to be taught, which will be retained throughout life. Similarly, for two research scenarios, both post-graduated and under-graduate participants were well aware of the ethical principles.
In scenario 4, more than half the participants responded that the patient should be informed about his illness as the dentist has to inform the patient before he/she either refuses to provide the treatment or provides the treatment. Since the disease is transmissible, the dentist should inform the patient but not to his relatives as this will breach con identiality.
Negativity among dental professionals is often encountered due to competitiveness among them. In scenario 5, the practising dentist faces the problem of deciding on the right option in treating a maltreated patient. Degrading the work of colleagues is again; violating professional ethics. Most dentists do not like to denigrate their colleagues. Though acting according to the patient's wish comprises autonomy, sometimes patients are not aware of the good and bad outcomes of the treatment, so the doctor or dentist should inform them about these and guide them to take an appropriate decision.
The 8th scenario created a con lict between the principles of truthfulness and bene icence. To overcome the dilemma, it is better to breach the principle which will be a bene it for the patient.
In the dental profession, it is dif icult at times to decide which principle to follow. Ethical principles are meant to guide the healthcare provider to serve humanity. As there is a hairline difference between the various principles, the following one can mean violating another. This results in moral distress, which has been de ined as knowing the ethically correct thing to do but feeling unable to act (Berg et al., 2001;Moayyeri et al., 2011;Jameton, 1984)

CONCLUSION
The survey explores the ethical dilemmas encountered by dentists in clinical practice in Chennai. The responses of the dental professionals regarding awareness towards ethical problems varied. However, many of the under-graduated practitioners with fewer years of experience were unaware of the principles. This necessitates providing a deep understanding and education not only towards ethical principles but also towards dental jurisprudence which will save the dentist and their patients from any uneventful situations.