As dentists, we also hold a position of trust within society. As a consequence, the society affords the profession certain privileges that are not available to the members of the public. In return, as dental professionals, we commit to society to adhere to the highest ethical standards of conduct. The American Dental Association (ADA) Code of Ethics is a set of ethical standards for dentists.
The code is based on five principles:
• Patient autonomy
• Nonmaleficence
• Beneficence
• Justice
• Veracity
The ADA Code of Ethics is a written expression of the obligations arising from the implied contract between the dental profession and society. The code is designed to help dentists maintain the high ethical standards of conduct that the public expects.
As the population continues to age, we are witnessing an unprecedented increase in the number of older adults with various types and levels of medical conditions, including mild cognitive impairment (MCI), and major neurocognitive disorders such as Alzheimer’s diseases, vascular dementia, and frontotemporal dementia. Given the limited number of specialized dentists trained to treat older adults with special needs, the ability to evaluate, diagnose, and manage the conditions and the behavioral manifestations of older adults will become an increasingly important part of the skill set of a general dentist.
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In addition to providing treatment modifications for our more complex patients, we also encounter rising ethical complexity when caring for older adults due to the need to handle multiple medical, cognitive, cultural, and social factors. The process of aging creates distinctive difficulties which may reduce a patient’s involvement in healthcare decisions so we have to remember to carefully and fully implement patient-focused care. Here are some of the challenges we may face while treatment planning for our older adults:
1. Cognitive Decline and Decision-Making Capacity
Assessing treatment consent capability in patients is an essential step. The presence of cognitive impairment requires clinicians to collaborate with family members and legal proxies while following the patient’s previously expressed wishes.
2. Advance Directives and End-Of-Life Care
A poll conducted by the University of Michigan in 2020 confirms that end-of-life care and medical decision-making is a difficult topic to broach for older adults. Nearly a quarter (23%) of respondents reported never having a conversation about their health care preferences, and 56% said they had not gotten around to it. The poll also finds that older adults may need more information about the importance of discussing end-of-life care and wishes, even if the final authorization forms have not been completed or signed. The findings suggest a significant need for increased awareness and education around the value of advance care planning. Notably, one in five individuals who had not engaged in these discussionsbelieved it was unnecessary, emphasizing the importance of proactive communication, even before formal documentations are completed.
3. Resource Allocation and Ageism
The need for additional medical resources among older adults creates challenges for distributing healthcare services fairly. The evaluation of individual healthcare requirements should replace age-based considerations to prevent discrimination against older patients.
4. Polypharmacy and Medical Overuse
Older adults face higher dangers from taking multiple medications at once. The ethical practice of prescribing medicine requires healthcare providers to reduce medication use without compromising the management of ongoing health conditions.
5. Cultural and Socioeconomic Factors
Healthcare ethics requires professionals to understand both cultural values and economic constraints that may affect the patient and/or the patient’s caregiver/power of attorney access and treatment choices.
To manage these challenges, we encounter intricate ethical decisions that demand collaboration between various healthcare providers including physicians, social workers, and pharmacists. The communication process requires both clarity and empathy when working with geriatric patients with complex medical conditions and the family members. The individualized care plan needs regular evaluation to update them according to the patient’s preferences and treatment objectives.
Strategies for Ethical Decision Making
• Foster Interdisciplinary Collaboration: The dentist should actively participate in the patient’s healthcare team with physicians, pharmacists, and social workers to make ethical and informed decisions that consider the patient’s health status. The need for interdisciplinary collaboration becomes most important in complex cases that involve multiple comorbidities, medications, or advanced age-related conditions.
• Specialized Training in Geriatric Ethics: Older adults face ethical challenges because their cognitive decline and multiple health conditions affect their ability to give consent. Dentists need specialized training in geriatric ethics to handle these situations with professional sensitivity while keeping patient autonomy and dignity at the forefront of care.
• Empathetic Communication of Medical Options: Older adults require dentists and their teams to explain treatment options through clear compassionate language which meets their cognitive and emotional needs. The use of straightforward explanations with empathy helps patients understand their treatment while also enabling caregivers to participate in decision-making when needed.
• Ongoing Assessment of Care Goals: Ethical dental care requires ongoing evaluation of treatment objectives which must align with changes in the patient’s medical status and their values and preferences. The patient’s quality of life and informed consent require ongoing dialogue about care objectives to make timely adjustments.
Conclusion
The ethical responsibilities of dental professionals extend beyond technical competence, encompassing the duty to uphold patient dignity and autonomy—particularly in the care of older adults facing complex medical, cognitive, and social challenges. The ADA Code of Ethics offers a foundational framework for maintaining integrity, justice, and compassionate care. However, applying these principles in geriatric dentistry often requires heightened ethical sensitivity, advanced clinical judgment, and effective interdisciplinary collaboration.
To meet the evolving needs of an aging population, dental practitioners must pursue ongoing education in geriatric ethics and maintain open, empathetic communication that fosters trust. Ethical practice in this context is not static; it is a continual process of self-reflection, humility, and patient-centered decision-making. As the demographic landscape shifts, so too must our commitment to delivering individualized, respectful care that integrates the full scope of each patient’s medical and personal history.
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References
1. American Dental Association. Principles of Ethics & Code of Professional Conduct. Revised to October 2024.
2. University of Michigan Institute for Healthcare Policy and Innovation. (2021, April 6). Poll: Despite pandemic, less than half of older adults have formally recorded what they want if they get seriously ill. https://ihpi.umich.edu/news-events/news/poll-despite-pandemic-less-half-older-adults-have-formally-recorded-what-they-want
3. Mukherjee A, Livinski AA, Millum J, Chamut S, Boroumand S, Iafolla TJ, Adesanya MR, Dye BA. Informed consent in dental care and research for the older adult population: A systematic review. J Am Dent Assoc. 2017 Apr;148(4):211-220. doi: 10.1016/j.adaj.2016.11.019. Epub 2017 Jan 5. PMID: 28065430; PMCID: PMC5376239.
4. Nitschke I, Hahnel S, Jockusch J. Health-Related Social and Ethical Considerations towards the Utilization of Dental Medical Services by Seniors: Influencing and Protective Factors, Vulnerability, Resilience and Sense of Coherence. Int J Environ Res Public Health. 2021 Feb 19;18(4):2048. doi: 10.3390/ijerph18042048. PMID: 33669815; PMCID: PMC7922367.
5. Mukherjee A, Livinski AA, Millum J, Chamut S, Boroumand S, Iafolla TJ, Adesanya MR, Dye BA. Informed consent in dental care and research for the older adult population: A systematic review. J Am Dent Assoc. 2017 Apr;148(4):211-220. doi: 10.1016/j.adaj.2016.11.019. Epub 2017 Jan 5. PMID: 28065430; PMCID: PMC5376239.
