Importance of ethics in oral pathology.

I feel extreme pleasure to share with you all that our association Indian Association of Oral and Maxillofacial Pathologists and International Chair in Bioethics (Formerly UNESCO Chair in Bioethics University of Haifa) have recently signed an Memorandum of Understanding (MOU) and jointly commits to promoting the cause of Bioethics as well as advocacy and awareness towards the principles of Bioethics among the honourable members of our association.

The term ethics refers to moral philosophy or a set of moral principles that regulate what is right, good, virtuous, true, and just, as defined by a culture or society.[1] Health care professionals always have the ethical responsibility to act in the best interest of the patient.

In addition to the standard moral and practice values published by Accredited Social Health Activistand other professional organizations, there are additional values that are relevant to medical ethics in both clinical care and research.[23] These include the following:

Autonomy

Beneficence

Nonmaleficence

Justice

Dignity

Truthfulness and Honesty.

AUTONOMY

The value of autonomy refers to the patient's (or the guardian's) right to be actively involved in making decisions about his or her own medical care. As oral pathologist, we describe the importance of various procedures as well as their drawbacks and give the decision-making power to the patients to choose their preferred treatment plan.

BENEFICENCE

It is a core value of health care because it involves actions that result in the well-being of others. The health care professional has the ethical responsibility to act in the best interest of the patient at all times. As oral pathologists, we have a responsibility to ourselves for the best outcome for the patient of society at large.

NON-MALEFICENCE

The word maleficence means doing harm or evil. Therefore, it is best described by the phrase “first do no harm.”. The health care practitioner must be reasonably sure that the patient will get benefit from the treatment prior to recommending the treatment. In histopathology laboratories nowadays, the lab technician uses a “sink test” for a small sample.

Sink testing is a form of laboratory diagnostics healthcare fraud where clinical specimens are discarded, via a sink drain and fabricated results are reported, without the clinical specimen actually being tested.[4] Giving a wrong report is doing harm to the patient health as the treatment of the patient will depend upon the reports of tests.

JUSTICE

It is the right of all individuals to have equal and fair access to health care resources. In a society where not all citizens have access to health care insurance, this value is often an ethical challenge for health care organisations and providers.

In oral pathology, there are many instances during the tissue processing that can lead to artifacts in the slides. Due to this, sometimes it might be difficult for an oral pathologist to give an exact diagnosis. Therefore, the pathologist must do justice to the patient by giving a correct diagnosis.

DIGNITY

The value of dignity relates to the basic human rights of the patient and family, which should be observed while they are being served in a health care setup. These may include:

The right to be treated with respect and dignity.

The right to ask questions.

The right to be involved in the treatment decision-making and to refuse treatment if desired.

The right to access the medical record.

The right to privacy and confidentiality.

TRUTHFULNESS AND HONESTY

They are two important pillars between the health care provider and the patient. A truly “informed” consent can only be given if the patient/family has a thorough understanding of the facts, implications and future consequences of proposed treatment. As oral pathologist, we should give detailed information about the reports given to the patients so that the patient fully understands and can make a further treatment decision for themselves.

BIOETHICS

According to UNESCO Bioethics can be defined as the systematic, pluralistic and interdisciplinary study involving the theoretical and practical moral issues raised by the life sciences and humanity's relationship with the biosphere.[4] Bioethics is the most suitable and ethical method of dealing with the condition that arises in the field of medicine, more so in current times with the beginning of new technology.

ETHICS IN ORAL PATHOLOGY

Ethical values should be taught to every dental student. As a professional we should:

Be aware of the responsibilities that we accept when entering the dental profession.

Meet the standards of competence, care and conduct while rendering service.

Above all the care of patients should be our first concern.

Ethics in research- Clinical trials.

Hence ethics forms an important dimension of a profession. The code of ethics prescribed by regulatory bodies as well as professional associations act as a guiding light in distinguishing between right and wrong, observing one's duties and maintaining good interpersonal relationships.

ETHICS FOR ORAL MAXILLOFACIAL PATHOLOGIST

The goal of the study is to bring some light on the ethics that are to be followed or faced by maxillofacial pathologists in their practice –

HISTORY

The first step is a collection of information by way of thorough history taking, which is often neglected. It is not only mandatory, but a professional responsibility to be aware of the patient's medical history of diseases that may affect the patient's dental treatment. It is also equally important to take medication histories, not only to prevent prescription errors and consequent risks to patients but also to detect drug-related clinical and/or pathological changes.

THE PATIENT-MAXILLOFACIAL PATHOLOGIST RELATIONSHIP

The relationship is unique as this branch is a bridge between dentistry and medicine. Most patient care responsibilities undertaken by a pathologist do not involve much face-to-face interaction. These responsibilities include interpreting a biopsy specimen, surgical resection, or cytology fluid sample; reviewing a peripheral blood smear or cytology, maintaining chemistry, microbiology, haematology, or molecular laboratory.

These responsibilities can involve sensitive information collected from patients' specimens therefore oral pathologists are obligated to protect patient's privacy, ensure that a specimen remains uniquely identified with a specific patient and treat patients' specimens, parts, and bodies with respect.[6]

DISCLOSING THE DIAGNOSIS TO THE PATIENT AND PHYSICIAN

In many cases, oral pathologists are physically detached from the patients whose care they influence, but physical separation does not abstain the pathologists to perform their duty to patients whose cells appear on a slide. In this regard, the obligation and responsibility of a pathologist are very crucial when it comes to disclosing the diagnosis of the patient.

Obligation to disclose to the patient. Principles of honesty and good faith apply to all physicians, so evading an obligation to share a preliminary diagnosis with a patient who desires that information can be perceived as dishonest and could have deleterious effects on the patient's emotional state and trust in the health care system. Direct communication between the pathologist and his or her clinical colleagues is a central principle of professionalism, and the same honesty and openness apply to the patient-pathologist relationship.

Obligation to disclose to the patient's referring physician. It is true in today's practice of medicine; patient care is team-based. Therefore, it is the primary duty of the maxillofacial pathologist to discuss and correlate the case with the referring physician as they have direct contact with the patient and know more about their clinical history.[7]

DESIGNING AND IMPLEMENTING A COMMUNICATION CURRICULUM

Traditionally, there has been little attention to teamwork and communication skills in pathology and laboratory training. The lack of focus on developing effective communication skills represents a major gap in the education of pathologists, as a lack of standardised expectations for conversations and explicit communication training could contribute to errors in information transfers between pathologists and other clinicians.

COMMISSIONS PRACTICE

Commissions for referrals (collectively called “cuts” or “kickbacks”) are a longstanding and widespread practice in Indian healthcare. They are now so much a part of mainstream healthcare, that most doctors have accepted them as a natural accompaniment to patient referrals. Periodic media exposure to this practice brings the issue transiently into public awareness, but it continues regardless. There is no question that commissions in healthcare, not only erode trust but also have other serious consequences. As well as leading to unnecessary tests and procedures, the money that exchanges hands is factored into patients' bills. This adds to the already high costs that citizens have to bear in India's growing private sector, which now dominates healthcare. Also, if referrals are based on commissions, the patient will likely be referred to the highest paying doctor and not to the most suitable one. Therefore, giving and receiving cuts is not just a matter of ethics, but it also increases the costs of care and decreases its quality.

DISCLOSING ERRORS

When errors occur in pathology and laboratory medicine, they can generate profound diagnostic confusion. These errors can take a variety of forms in different subspecialties. Errors in laboratory medicine and clinical pathology can occur at any point from specimen retrieval through specimen analysis; they are classified broadly as pre-analytic phase, analytic phase and post-analytic phase errors. Preanalytical phase errors take place before the specimen arrives in the pathology lab and comprise the majority of laboratory errors, analytic phase errors take place during the laboratory processing and analysis of the specimen, and post-analytic phase errors take place during the reporting of the lab results to clinicians and clinicians' interpretation of those results. Transparency in their regard is desirable.

IMAGE-SHARING: A PRIVACY PROTECTIONS

Although the accessibility of social media has raised questions about whether more strict privacy standards should be implemented and enforced, it is easy to forget that journal-based reports are also publicly available, even if access is fee- or library-based.

Therefore, some guidelines have been issued by American Medical Association (AMA) protecting patient privacy for clinicians using social media.[8]

DISCLAIMER – TO CORRELATE CLINICALLY??

In the pathological report, we often see the sentence: Clinical correlation is recommended. “This simply means that mere examination of the pathologic material (like histology, immunohistochemistry results, etc) alone may not suffice, but must be correlated with the patient's clinical findings, chief complaint and presentation, relevant physical examination and other relevant additional tests such as biochemistry results, and imaging studies (like CT scan, MRI, etc.) under the context of a “Multidisciplinary Team (MDT”) approach in the evaluation and management of patients. In this perspective, a better understanding of the disease, its definitive diagnosis, and most importantly, proper and correct management and treatment is not compromised is recommended.

CONCLUSION

Bioethics plays a significant role in medical and dental practice. Dental professionals are one of the healing professions, therefore, they have an obligation to society for adhering to high ethical standards and conduct. The code of ethics teaches all clinicians to put their patients first, to involve the patient in treatment decisions, to consider the patient's expectations during treatment planning, to respecting their decision regarding the treatment and to maintain the confidentiality of the patient. Without a solid ethical foundation, one cannot be a true professional so ethics are critical to being a professional.

Also, there are no such guidelines or protocols formed for the oral pathologist to be followed given by the Indian Association of Oral and Maxillofacial Pathologists” (IAOMP) or the Indian Dental Association (IDA). There is a need for some protocols, ethics and rules to be formed by these organisations to create more discipline amongst the maxillofacial pathologist so that they could deliver the best to their patients. As well as bioethical values, such as human rights, dignity, respect for autonomy and vulnerability must be discussed and incorporated into clinical practice as well as in academic institutions. The declining index of patients' view of ethical standards in the health care system is demeaning. It is high time we take protective steps and put our house in order to ensure that ethical practice must be strictly pursued.

Types Of Potentially Identifying Information	Recommendations
Date	Avoid saying, “today I saw a case of rare entity X” or “yesterday I diagnosed entity Y.” Never use dates. Be intentionally vague.
Unusual or newsworthy circumstances	Avoid information disclosure that could allow direct association with a recent crime or accident. Consider delay in posting cases that are highly unusual.
Identifying images	Avoid posting full facial images, unique tattoos, or other identifying features without explicit patient permission.
Age	Approximate ages are a good idea for all posts even though not legally required. Precise age should be avoided.
Geography	Avoid mention of small geographic subdivisions where the patient might have originated.