Staff Relationships

Dentists who responded to the case chose either to continue to monitor Sarah’ s behavior (option #1) or discuss the issue with Sarah, and if she discloses that she is a substance abuser, offer to pay for substance abuse counseling (option #3). None of the respondents chose just to confront her with the issue (option #2) or discuss the concerns with Sarah and then dismiss her if she discloses that she is a substance abuser (option #4). What are the ethical obligations of dentists to their employees as in Sarah’s case and how do those obligations vary from situations where a colleague is suspected of substance abuse? Respondents to this case described a true ethical dilemma because of the conflict of preventing harm and maintaining loyalty to both Sarah and the patients in the practice.

Prevent Harm/Maintain Loyalty

First, patients trust that their doctors will prevent unnecessary harm to them during treatment, a primary principle of the health professions.¹ Respondents wrote that the “doctor/employer has a significant liability risk in this case,” and that it is “probably too high a risk to take.” Society grants certain privileges to professions because they perform an important service but, society also expects the professions to be self-regulating² because it is primarily the profession that has the knowledge and skills to assess competence. Providing quality care in a competent manner² is a central value for the dental profession³ and a common value of the health professions. The ADA Code of Ethics was revised in 1993 to include section 1-N (Chemical Dependency) that states:

“It is unethical for a dentist to practice while abusing controlled substances, alcohol or other chemical agents which impair the ability to practice. All dentists have an ethical obligation to urge impaired colleagues to seek treatment. Dentists with first-hand knowledge that a colleague is practicing dentistry when so impaired have an ethical responsibility to report such evidence to the professional assistance committee of a dental society.” ²

Although the ADA Principles of Ethics does not address dental auxiliaries, patients also expect that their doctors will prevent harm by impaired dental auxiliaries. In this regard, the obligation to prevent harm by chemically-dependent practitioners may be extended to include dental auxiliaries.

Second, dentists recognized the ethical dilemma between confronting Sarah and protecting patients as one of conflicting loyalties, since she has been a long time employee who has become an integral member of the practice. One respondent said that she should “warrant extra consideration” and that her welfare should also be a concern. Dentists may feel an obligation to help their employees when they are faced with personal problems that affect their work. They may also feel an obligation to confront an employee as in Sarah’s case because she is a friend who needs help.

The ethical dilemma then is that one cannot chose to ignore Sarah’ s suspected impairment without the possibility of exposing patients to harm. What are some alternatives to the doctor/employer who encounters a case like Sarah’s?

Intervention

There are chemical dependency and well-being or help programs at the national, state, and local level of constituent and component dental societies.⁴ Many of these programs while assisting dentists may also provide services for dental team members.

The ADA through the Council on Dental Practice coordinates national and state activities and educational programs for chemical dependency, mental health issues and HIV/AIDS. The Council recently published the 1994 Directory: Dentists’ Chemical Dependency and Well Being Programs, a resource guide that identifies the contacts for programs in all states. Linda Crosby is the Manager of the Dentist Well Being Program at the ADA and she can be reached at (800) 621-8099, extension #2622.

One respondent asked if Sarah would be eligible to participate in the Texas Dental Peer Assistance Program (TDPAP). Bob Robinson, the Director of TDPAP, says that the purpose of the program is to “save lives and help people,” and that, although the program was established for licensed dentists and dental hygienists, dental assistants and office staff are also eligible and have received assistance. In Sarah’s case, the TDPAP in addition to offering counseling could also advise the dentist in how to investigate if she was receiving controlled substances through forged prescriptions from the office or phoned to the pharmacy and make suggestions on ways to proceed if these suspicions prove to be true. One respondent was concerned that he may be personally responsible for expensive counseling services; however, one of the services of the TDPAP is to coordinate financial arrangements for the client which does not involve the referring dentist. The program is a non-profit Texas Corporation that provides services regarding chemical dependency and also mental health issues, sexual issues, eating disorders, and family counseling. The TDPAP relies on peer assistance, not peer review, and the agency monitors all treatment referrals and coordinates activities with local dental societies as peer assistance is regulated by state laws. The agency receives funding from licensure fee surcharges and state dental agency contributions and has the support of organized dentistry in Texas. The TDPAP has a confidential “Hope Line” (800-945-6203) that provides access to this peer assistance program.

Dentists Concerned for Dentists (DCD) is a local peer assistance program which has a 15- year record of leadership in Texas. Jim Hill, a dentist and Executive Director, explained how DCD established a local program that had an impact on the formation of the TDPAP. The Texas Dental Peer Assistance Program was established at the state level to alleviate the need for each county to burden the responsibility of dealing with these issues. If a dental society is aware of a problem, the TDPAP should be notified immediately.

Conclusion

Sarah’s case has challenged us to consider our obligations to patients and employees when a dental assistant has a possible substance abuse problem. Although the obligation to report colleagues is clear, there is less guidance for the dentist as employer. While respondents agreed that preventing harm to patients was paramount, how to proceed was troublesome. Members of the dental team who exhibit documentable behaviors of substance abuse may harm patients, and the dentist is justified and even obligated in this case to discuss the concern with Sarah and may offer support through available dental peer assistance programs.

References

1. Campbell CS Rogers VC. The normative principles of dental ethics. In: Weinstein BD ed. Dental Ethics. Philadelphia, PA: Lea & Febiger; 1993:28-29.
2. ADA Principles of Ethics and Code of Professional Conduct. May 1994:7.
3. Ozar DT Sokol DJ. The questions of professional ethics. In Dental Ethics at Chairside: Professional Principles and Practical Applications. St. Louis: CV Mosby; 1994:33.
4. Parker LS Hollway JH Professional responsibility toward incompetent or chemically dependent colleagues. In: Weinstein BD ed. Dental Ethics. Philadelphia, PA: Lea & Febiger; 1993:101-115.

Dentists who responded to the case chose one option listed: call Giles and describe your concerns to him before the next appointment, and if he doesn’t deny these allegations, dismiss him immediately. None of the dentists chose the options: 1) don’t be overly concerned about this situation; 2) at the next appointment, make sure you are near the operatory to listen to Giles and decide if he is sexually harassing the dental hygienist; 3) refer him to a periodontist for further treatment; 4) call Giles and describe your concerns to him before the next appointment, and if he denies these allegations , dismiss him anyway; or 5) call Carole and explain your concerns about his behavior based on the common concerns of your dental team, and that you are dismissing him from your practice. Dentists offered several alternatives to the options listed.

What obligation does the dentist have when a patient makes repeated inappropriate and sexually suggestive comments, or tries to hug or touch an employee? The variety of comments by dentists to this case was helpful in revealing the complexity of sexual harassment. Addressing the subtleties of the topic requires more space than available in this response. We will address four aspects of sexual harassment including: 1) current definitions; 2) occurrences in practice and during training; 3) trust within the dental practice; and 4) preventive ethics and sexual harassment.

Defining Sexual Harassment

The potential for sexual harassment in the dental office is high as dentists and dental hygienists provide care in close physical proximity to patients. The practitioner and patient are usually face-to-face, and treatment often requires multiple appointments. When does behavior by patients like Giles Pender become sexual harassment?

The Equal Employment Opportunity Commission’s (EEOC) “Guidelines on Discrimination Because of Sex,” defines sexual harassment as follows:

“Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature constitute sexual harassment when 1) submission to such conduct is made either explicitly or implicitly a term or condition of an individual’s employment, 2) submission to or rejection of such conduct by an individual is used as the basis for employment decisions affecting such individual, or 3) such conduct has the purpose or effect of unreasonably interfering with an individual’s work performance or creating an intimidating, hostile, or offensive working environment.”¹

The term, “unwelcome” and the phrase “hostile working environment” relate directly to the case. A clearer explanation of the term “unwelcome” targets behavior that is “one-sided, unsolicited, unwelcome, repetitive, and clearly not under the control of the victim.”² Apparently, Giles’s behavior is unwelcome by both the dental hygienist and the receptionist. The dental hygienist has already warned Giles that his remarks were inappropriate, but his behavior persists. His behavior, mostly verbal, may be contributing to a hostile work environment for the staff. According to a Supreme Court decision in 1993, offensive language alone may constitute sexual harassment. Justice Sandra Day O’Connor wrote the opinion stating that Title VII of the Civil Rights Act of 1964 prohibiting sexual harassment “comes into play before the harassing conduct leads to a nervous breakdown.”³ (93 Daily Journal DAR 14212, 14213).

While most of the EEOC Guidelines address employers and employees within a business, employers “may also be responsible for the acts of non­-employees, with respect to sexual harassment of employees in the workplace, where the employer (or its agents or supervisory employees) knows or should have known of the conduct and fails to take immediate and appropriate corrective action.”¹ For example, non employees could be customers who sexually harass a server at a restaurant, or patients who harass nurses or dental hygienists.

The federal EEOC Guidelines apply to businesses where there are at least 15 employees, which is higher than the typical dental practice. The published codes of ethics of the American Dental Association, Texas Dental Association, and the American Dental Hygienists’ Association do not address sexual harassment in dental or dental hygiene practice.

Occurrences in Practice and Training

Dentists and dental hygienists often report verbal and physical sexual harassment by patients during training and in practice. In a survey of Oregon dentists and dental hygienists, for example, 44 percent of the dental hygienists who responded experienced verbal harassment at approximately one incident per year over five years, while 23 percent reported physical harassment at a rate of three incidences over five years. Dental hygiene respondents to the survey reported twice as many total incidences as the dentists.⁴

A survey of female dentists affiliated with the TDA and female junior and senior dental students at the three Texas dental schools addressed sexual harassment experiences, the reason for tolerating the behavior, and the manner in which the offensive behavior was handled. The dentists who responded reported that 46 percent are “sometimes” sexually harassed by a patient and one percent “often” harassed.⁵ The dental students that responded reported that 48 percent are “sometimes” harassed by a patient and nine percent “often” harassed. The study identified seven types of harassment. The “persistent request for social interaction outside the health care environment” was the most frequent harassment reported by female dentists (47 percent) and dental students (67 percent). Being coerced to listen to sexual remarks or jokes was second highest reported by the dentists (41 percent) and dental students (57 percent). Being touched without consent was the third highest reported by dentists (37 percent) and dental students (30 percent).

What are the ethical obligations concerning protecting the dentist’s staff from sexual harassment?

Trust in the Dental Office

Trust between the dentist and patient is a mutual expectation in the doctor-patient relationship.⁶ Patients also place their trust in dental assistants and dental hygienists, and dentists promote this trust as part of the obligation to benefit the patient.^7,8 What role does trust play within the dental office?

One female dentist with over 15 years of general practice experience explained, “This has happened a couple of times to me already. I believe my office staff 100%. Never doubt them about this, or you will lose their loyalty.” Two values that promote loyalty and trust within the dental office are justice and mutual respect for autonomy.⁷

The ethical principle of justice has been closely linked to the concept of desert or “giving to each his right or due.⁹” For example, a dentist acts justly when providing fair employment compensation to the office staff.⁷ A dentist also acts justly by confronting Giles regarding his inappropriate behavior, if the incident is verifiable and carefully documented. As one dentist said, “I must provide a safe environment for my employees to work,” and this safety extends beyond hazardous working conditions to include patients who sexually harass. Mutual respect for autonomy between the dentist and dental hygienist acknowledges that each person brings expertise for the benefit for the patient. The philosopher David Ozar has characterized this relationship as a general commitment to collaboration for the greater benefit of the patient.¹⁰

There was no consensus on how the dentist should manage the case. None of the dentists chose to simply ignore the situation or to contact the patient’s wife explaining his dismissal from the practice. A male dentist said that he would complete the three-root planning and scaling appointments for Giles along with the replacement of the amalgams. He explained, “This would allow me to observe any inappropriate behaviors and finish his dentistry at the same time while avoiding embarrassing and awkward confrontations with the hygienist.” This may temporarily solve the problem for the dental hygienist, but it does not help the receptionist. The dentist can observe the patient, but Giles may be cautious and avoid this behavior unless in the presence of the hygienist or receptionist alone. As one dentist noted, “some sexual harassers are sneaky – they don’t act up if you are present.”

To provide the safe environment for her employees, one dentist noted that she would give Giles two choices: 1) see another dentist immediately, [following proper legal guidelines to avoid patient abandonment]; or 2) clean up his act – verbal and physical. At this point, if he became agitated or abusive, the dentist would escort him politely to the door. She would take a loss on any monies owed to the office, and would write a dismissal letter following proper legal guidelines.

Preventive Ethics

Preventive ethics promotes the view that rather than reacting to ethical problems in practice, the preventive approach is, “less expensive, more effective, and less traumatic emotion­ally than litigation, bureaucratic regulation, or misunderstandings between physicians, patients, and families.”¹¹

Prevention is promoted in the EEOC Guidelines as the best tool for the elimination of sexual harassment. Each employer should take all steps necessary, including, “affirmatively raising the subject, expressing strong disapproval, developing appropriate sanctions, informing employees of their right to raise and how to raise the issue of harassment under Title VII, and developing methods to sensitize all concerned.¹” The author Gerald Nelson promotes prevention in the orthodontic practice by recommending a written office policy. The written policy lists prohibited behavior and defines harassment of non-employees, monitoring strategies, and disciplinary procedures. It also describes a com­plaint procedure that includes the designation and training of a sexual harassment counselor for the office.¹² For students in dental and dental hygiene programs, the author Gary Chiodo offers a 3-step intervention model for the curriculum. The model provides an opportunity for students to view and discuss various scenarios in a seminar format during their training. The author reports, because of the seminars, “Those providers who are prepared for the possibility of patient advances seem better able to arrest the problem while maintaining a useful provider-patient relationship. Unprepared providers are more likely to either react in a manner that will perpetuate the problem or to overreact in an attempt to punish the patient.”⁴

Conclusion

Dentists may use reasonable discretion in selecting patients for their practices.⁸ Patients who sexually harass employees verbally or physically undermine the trust within the practice. Preventing sexual harassment is a worthy goal in dental practice. If sexual harassment occurs, the dentist is obligated to verify and carefully document each incident and is justified in discontinuing patient care (following proper legal guidelines).

References

1. Equal Employment Opportunity Commission. Guidelines on discrimination because of sex. In: EEOC Rules and Regulations. Chicago: Commerce Clearing House; 1980; 45(72): 25024- 25025.
2. Libbus MK, Bowman KG. Sexual harassment of female registered nurses in hospitals. JONA 1994;24(6):26-31.
3. Zuffoletto JM. OR nursing law: Supreme Court rules on landmark sexual harassment case. OAORN J 1994;59(2):529-530.
4. Chiodo GT, Tolle SW, Labby D. Sexual advances by patients in dental practice; Implications for the dental and dental hygiene curricula. J Dent Educ 1992;56(9):617-624.
5. Telles-Irvin P, Schwartz IS. Sexual harassment among female dentists and dental students in Texas. J Dent Educ 1992;56(9):612-616.
6. The good patient & the good physician. In: Pellegrino ED, Thomasma DC eds. For the patient’s good. New York: Oxford University Press; 1988:99-124.
7. Gaston MA, Gladwin MA. Relationships with dental hygienists and dental assistants. In: Weinstein BD ed. Dental Ethics. Philadelphia: Lea & Febiger; 1993:117-123.
8. ADA Principles of Ethics and Code of Professional Conduct. American Dental Association May 1994: 1.
9. The principle of justice. In: Beauchamp TL, Childress JF eds. Principles of biomedical ethics. New York: Oxford University Press; 1983:184.
10. Working together. In: Ozar DT. Dental ethics at chairside: professional principles and practical applications. St. Louis: Mosby; 1994:165-187.
11. Pellegrino ED, Siegler, Singer PA. Future directions in clinical ethics. J Clin Ethics 1991;2(1):5-9.
12. Nelson G. Litigation and legislative update. Sexual harassment: An issue in the orthodontic office? Am J Orthod and Dentofacial Orthop 1993; 104(4):417-418.