Continuing benefits of the Montreal Protocol and protection of the stratospheric ozone layer for human health and the environment.

The protection of Earth's stratospheric ozone (O3) is an ongoing process under the auspices of the universally ratified Montreal Protocol and its Amendments and adjustments. A critical part of this process is the assessment of the environmental issues related to changes in O3. The United Nations Environment Programme's Environmental Effects Assessment Panel provides annual scientific evaluations of some of the key issues arising in the recent collective knowledge base. This current update includes a comprehensive assessment of the incidence rates of skin cancer, cataract and other skin and eye diseases observed worldwide; the effects of UV radiation on tropospheric oxidants, and air and water quality; trends in breakdown products of fluorinated chemicals and recent information of their toxicity; and recent technological innovations of building materials for greater resistance to UV radiation. These issues span a wide range of topics, including both harmful and beneficial effects of exposure to UV radiation, and complex interactions with climate change. While the Montreal Protocol has succeeded in preventing large reductions in stratospheric O3, future changes may occur due to a number of natural and anthropogenic factors. Thus, frequent assessments of potential environmental impacts are essential to ensure that policies remain based on the best available scientific knowledge.

The response of the ozone layer to quadrupled CO2 concentrations.

An accurate quantification of the stratospheric ozone feedback in climate change simulations requires knowledge of the ozone response to increased greenhouse gases. Here, we present an analysis of the ozone layer response to an abrupt quadrupling of CO2 concentrations in four chemistry-climate models. We show that increased CO2 levels lead to a decrease in ozone concentrations in the tropical lower stratosphere, and an increase over the high latitudes and throughout the upper stratosphere. This pattern is robust across all models examined here, although important inter-model differences in the magnitude of the response are found. As a result of the cancellation between upper and lower stratospheric ozone, the total column ozone response in the tropics is small, and appears to be model dependent. A substantial portion of the spread in the tropical column ozone is tied to inter-model spread in upwelling. The high latitude ozone response is strongly seasonally dependent, and shows increases peaking in late-winter and spring of each hemisphere, with prominent longitudinal asymmetries. The range of ozone responses to CO2 reported in this paper has the potential to induce significant radiative and dynamical effects on the simulated climate. Hence, these results highlight the need of using an ozone dataset consistent with CO2 forcing in models involved in climate sensitivity studies.

Cosmetic treatment, autonomy, and risks: "if you don't do it, I'll go to a dentist who will".

Patient requests and treatment goals may exceed the limits of professional practice and may have an adverse effect on health. When doctors encounter these types of requests, they first must decide whether the patient has the capacity to consent to such care. In the case of child patients, no such capacity exists and surrogate consent to care must be, in the opinion of the doctor, in the child's best interests. Parents who request potentially harmful procedures for a child with no hope for any health care benefit should be refused politely. Adult patients who request harmful elective procedures for themselves also should be educated and helped to fully understand why the request represents substandard treatment. The long-term consequences of these requests must be detailed clearly for these patients. Elective cosmetic treatment that will lead to long-term adverse effects on function and health raises serious ethical concerns in which the principle of nonmaleficence likely will trump the patient's autonomy.

Virtue versus ethical obligations: working for system-wide change.

Clinical ethics issues most often focus on the individual encounter or relationship between a specific doctor and patient. This is an appropriate focus, since this dynamic defines the normal course of health care delivery and it is within this relationship that most ethical dilemmas arise. Once a provider has discharged his or her ethical duties to a particular patient, further efforts toward assisting that patient or toward social policy affecting health care in general are virtuous but are not ethical mandates. Issues of distributive justice in health care allocation and reimbursement are examples of policy issues that impact persons who may not be patients in one's practice but who may benefit from the actions of the dental profession. Many times, as in the case presented, the dentist's awareness of such issues of distributive injustice may arise from an individual patient encounter. In the process of attempting to secure justice for a particular patient, the dentist may become aware of the broader social context of the problem. This awareness calls upon dentists, just as it calls upon other health care providers, to become involved via their professional organization and to work for distributive justice. While individual values may mediate the duty to advocate for many social issues, professional values that are oriented toward improving the health and well-being of all in a society require organized health care professions to advance these causes.

Is there a doctor in the house?

The two cases presented deal with urgent situations experienced by persons unknown to the dentist in the area. It is likely that dentists, physicians, nurses, and other medical professionals will encounter persons in urgent need of medical attention in other venues. Certainly, it is possible for someone to experience an emergency in a ballpark, grocery store, church, or other public gathering. While these settings may not offer the advantage of a medical emergency kit, they do pose the same ethical requirement for those trained in medical management of urgent problems to step forward, identify themselves, and attempt to help the ill person. Fortunately, most non-air settings usually allow for contacting emergency medical help and prompt transport to hospitals. The public may never reach a general understanding of the extent to which doctors other than physicians are trained to handle medical emergencies. Similarly, when someone in a crowded theater yells, "Is there a doctor in the house?" he or she most likely is thinking about a physician. This does not mean that a dentist is excused from acting as a medically trained Good Samaritan. The ethical obligation of specific beneficence requires dentists to minister to the ill in medical emergencies unless a more qualified health care provider is present and identifies himself or herself. The ethical obligation of general beneficence requires dentists and other citizens to assist those in urgent circumstances whose needs do not call upon specialized knowledge or training. Fortunately, the law in this country is designed to protect those who do attempt to help those in need.

Ethical duties when patients make suspicious narcotic requests.

Practicing dentists are likely to be familiar with the prospect of patients who request controlled substances for doubtful indications. Torn between ethical obligations of beneficence and nonmaleficence, the dentist may be uncertain whether to prescribe a medication with the intention of alleviating pain or to refuse the prescription due to concerns related to chemical dependency, underlying emotional illness, or ulterior motives on the part of the patient. Pharmaceutical choices often do not provide a mechanism for sidestepping this dilemma as chemically dependent patients may be quite sophisticated in their knowledge of drugs and the ways in which to couch their requests. Dentists have an ethical obligation to move beyond simply refusing prescriptions for patients suspected to be chemically dependent; they should sensitively discuss the issue with these patients and be prepared to offer referral for intervention. However, dentists must always be open to the possibility that a particular patient's assertion of chronic physical pain may be of complex origin. When this is the case, appropriate treatment is essential and may involve referring the patient to others with specialized skills. Dentists should not withhold pain medication from patients with uncontrolled pain in the final stages of life.

The dentist's role in bereavement support.

An aging population that is retaining more dentition and an increasing number of persons affected by terminal illnesses have resulted in dentists encountering dying patients and patient deaths with increasing frequency. These events call upon dentists and their staffs to provide support for the terminally ill and for survivors of the deceased. Dentists are effective in providing bereavement support and survivors benefit greatly from it. However, this type of support is stressful for dentists and many report the need for more formal education in this area. The ethical basis for dealing effectively with a dying patient's need for open and honest discussion derives from the obligations of the doctor-patient relationship. These ethical requirements carry over to providing some level of bereavement support for the surviving loved ones of the deceased and address the professional duties of compassion and care. Sending a sympathy card with a personal note, attending the patient's funeral, or making a follow-up telephone call to the patient's survivors are all appropriate, beneficial, and appreciated.

Treatment recommendations: "doctor knows best".

Patients often develop an abiding trust in their health care providers and may agree with any recommendations that a dentist offers. This level of trust is a compliment to the dentist and the profession. However, patients who request that a doctor perform the treatment that he or she feels is best and who prefer to avoid an informed consent process must be educated as to the role of informed consent and their part in the process. Even when a patient is adamant in refusing information about his or her condition or states a clear reason as to why he or she does not desire to know a diagnosis or treatment plan (for example, dental phobia or fear of cancer), the dentist has an ethical and legal obligation to work with an appropriate surrogate of the patient's choice and make reasonable attempts at including the patient in the discussion. These patients should be offered the option of discussing the diagnosis and treatment alternatives with a family member or friend present and may include such a surrogate in the informed consent process. When patients clearly lack capacity to consent, the process of informed consent will revert automatically to appropriate surrogates. Finally, patients from different cultures may bring a new set of considerations to the process of informed consent and may require that a modification of the Western tradition be considered, allowing a significant role for the family of the patient in making treatment decisions.

Disclosure of mistakes.

In the course of professional practice, errors will occur and patients may be harmed because of them. The ethical obligation to respect patients' autonomy requires that dentists reveal mistakes to patients if the mistake significantly affects the patient's health and well-being. Answering the question, "would most people think they have a right to know of this type of mistake if it happened to them?" may be helpful in determining the significance of an error. An open disclosure and examination of professional mistakes will be beneficial to patients, doctors, and the practice. Fear of legal reprisals or thoughts that the mistake could be effectively concealed from the patient cannot justify failing to inform the patient of an error and may put the dentist in greater legal peril. Dentists who attempt to hide errors from patients violate the patient's autonomy and risk implicating the profession as one which cannot be trusted.

Ethical issues in the acceptance of gifts: Part 1.

It brightens the day of any health care provider when a patient presents him or her with a personal gift. These thoughtful items express sincere appreciation and are evidence of a solid, trust-based provider-patient relationship. However, there is a significant ethical difference between accepting small gifts of appreciation versus gifts of great financial value. While the patient may be expressing the same appreciation with this substantial gift, he or she may also be attempting to curry special consideration or feel some pressure to please the provider. In addition, acceptance of these large gifts produces the appearance of an improper relationship between the doctor and the gift-giving patient. Patients who offer gifts of great value should receive a sensitive explanation as to why the gift cannot be accepted.

Sexual boundaries in dental practice: Part 2.

Sexual harassment in the workplace is harmful to employees and disruptive. While the ethical obligations arising from the doctor-patient relationship do not address a dentist's ethical obligations toward his or her employees, the more general ethical obligations to the profession and those of business ethics would mediate against the creating or tolerance of sexual harassment in the workplace. The legal implications of participating in sexual harassment or allowing it to persist in the dental office are significant and dentists should be aware that employees enjoy legal protections against this inappropriate and potentially unlawful behavior. While any gender in any position may be the victim of sexual harassment, women who occupy subordinate positions are the most likely targets of these overtures. Dentist-employers are wise to be proactive in providing an appropriate protocol for employees to use when they perceive sexual harassment in the workplace.

Sexual boundaries in dental practice: Part 1.

Sexual contact between doctors and patients is unethical, legally perilous, cause for professional discipline at times, and often viewed as an outrageous transgression by the public. While it is true that some provider-patient couples go on to get married and "live happily ever after," this is not always the case. However, if these relationships fail, a now embittered ex-paramour is empowered with the options of bringing legal and/or disciplinary action against the doctor and may be motivated by the distinct possibility of significant financial reward. Patients place enormous trust and respect in their health care providers. In addition, patients reveal sensitive, confidential information to doctors and do so with the expectation that it will be used only for their best interests. This dynamic creates a substantial power imbalance between doctors and patients and this power differential must never be exploited. Dentists who find themselves romantically attracted to patients must either avoid initiating a more intimate relationship or refer the patient to another provider. Dentists who are the recipients of romantic inquiries by patients should establish clear boundaries. If the dentist is available and interested in the patient, dating may occur only after the patient has been reassigned to another dentist and a suitable time period has elapsed.

Managed care--serving two masters.

It is likely that enrollment in managed care dental plans will continue to increase. Dentistry can respond to this trend by resisting it; however, just as the health care marketplace drove medical care into managed care mechanisms, so too will these forces impact dentistry. For those who are participating in managed care dental plans, it is heartening that current data indicate that most types of patient care are not adversely affected by reimbursement mechanisms. Dentistry, however, should seek out opportunities to shape the managed care format and must be at the table to assure that ethical principles and conflicts of interest receive due consideration. Dentists who treat patients under a managed care reimbursement system must be certain that the plan does not require providers to sacrifice patient autonomy or compromise care in the process of serving two masters.