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Persona y Bioética

Print version ISSN 0123-3122

pers.bioét. vol.21 no.1 Chia Jan./June 2017

http://dx.doi.org/10.5294/pebi.2017.21.1.2 

Artículos

Ethical Conducts of Professors, Undergraduates and Graduate Students: The View of Dental School Patients

Conducta ética de parte de los profesores, estudiantes de pregrado y postgrado: el punto de vista de los pacientes de algunas escuelas odontológicas

Conduta ética de professores, estudantes de graduação e pós-graduação: o ponto de vista dos pacientes de algumas faculdades de odontologia

Letícia Oliveira Tonin1  , Letícia Ferreira dos Santos2  , Cristhiane Leão de Queiroz3  , Julia Gabriela Dietrichkeit Pereira4  , Ricardo Henrique Alves da Silva5 

1 orcid.org/0000-0002-1067-3749. University of São Paulo, Brasil. leticia.tonin@usp.br

2 orcid.org/ 0000-0003-4199-0402. University of Sao Paulo, Brasil. leticia.ferreira.santos@usp.br

3 University of Sao Paulo, Brasil. cristhianeleao@gmail.com

4 orcid.org/0000-0003-1129-0755. University of Sao Paulo, Brasil. juliadie@gmail.com

5 orcid.org/0000-0002-1532-1670. University of Sao Paulo, Brasil. ricardohenrique@usp.br

ABSTRACT

Introduction:

The importance attached to ethical practice and related informed consent varies among health professionals and is further influenced by working environments, level of knowledge, experience and societal values and beliefs. The objective of this study is to evaluate the ethical conduct of professors, undergraduates and graduate students through questionnaires answered by patients.

Methods:

One hundred twenty (120) patients at the dental clinics of three different dental schools in São Paulo State were interviewed based on objective and discursive questions about signed informed consent, participation in scientific research, photographs during treatment, requested saliva samples, tooth donation requests, and information about tooth destination after removal. A frequency distribution (absolute and percentage values) was used for a statistical analysis of the data.

Results:

In all, 65.8% of the patients had given signed informed consent for treatment and 12.5% had not done so; 10.8% did not know if they had participated in scientific research; 54.2% were photographed during dental procedures and 47.1% of them had signed an authorization form; 6.6% were requested to provide a saliva sample and 66.6% of them had signed an authorization form to that effect; 16.1% had a tooth donation requested and 64.4% of them had signed an authorization form to that effect; and 61.3% did not know the destination of the tooth after removal, when donation was not requested.

Conclusions:

The majority of the patients had signed an informed consent form for treatment, photographs, saliva samples and tooth donation. This demonstrated ethical conduct towards patients on the part of professors, undergraduates and graduate students.

Key words: Ethics; bioethics; dentistry; research; informed consent

RESUMEN

Introducción:

la importancia atribuida a la práctica y al consentimiento informado varía entre los profesionales de salud. Esto es aun más influenciado por el entorno laboral, nivel de conocimiento, experiencia, valores y creencias sociales. El artículo tiene como fin evaluar las conductas éticas de profesores y estudiantes de pregrado y postgrado por medio de cuestionarios con pacientes.

Métodos:

120 pacientes de clínicas odontológicas de tres diferentes facultades del departamento de São Paulo fueron entrevistados con preguntas discursivas y objetivas acerca de la firma del consentimiento informado, participación en investigación científica, fotos durante el tratamiento, solicitud de muestra de saliva, solicitud de donación de diente e información sobre el destino de este luego de removido. Para el análisis estadístico de los datos, se utilizó distribución de frecuencia (absoluta y porcentual).

Resultados:

el 65,8% de los pacientes firmó el consentimiento para tratamiento y el 12,5% no lo firmó. El 10,8% desconoce si ha participado de investigación científica. El 54,2% ha sido fotografiado durante los procedimientos odontológicos y, de ellos, el 47,1% firmó un término de autorización. A un 6,6% se les solicitó saliva y el 66,6% de ellos firmó una autorización. El 16,1% recibió una solicitud de donación de los dientes y, de ellos, el 64,4% firmó una autorización. El 61,3% desconocía el destino del diente luego de su remoción cuando la donación les fue solicitada.

Conclusiones:

la mayoría de los pacientes firmó el consentimiento para tratamiento, fotografías, muestra de saliva y donación de dientes. Ello demuestra qué conductas éticas ante a los pacientes se están siguiendo por los profesores y estudiantes de pre y postgrado.

Palabras-clave: bioética; consentimiento informado; ética; odontología; investigación

RESUMO

Introdução:

a importância atribuída à prática ética e ao termo de consentimento varia entre os profissionais de saúde. Isso é ainda mais influenciado pelo ambiente de trabalho, nível de conhecimento, experiência, valores e crenças sociais. O objetivo deste artigo foi avaliar as condutas éticas de professores e alunos da graduação e da pós-graduação por meio de questionários com pacientes.

Métodos:

120 pacientes de clínicas odontológicas de três diferentes faculdades de odontologia do estado de São Paulo foram entrevistados com perguntas discursivas e objetivas sobre assinatura de termo de consentimento, participação em pesquisa científica, fotos durante o tratamento, solicitação de amostra de saliva, solicitação de doação de dente e informação sobre o destino do deste depois de removido. Para a análise estatística dos dados, foi utilizada distribuição de frequência (absoluta e valores percentuais).

Resultados:

65,8% dos pacientes assinaram o termo de consentimento para tratamento e 12,5% não o assinaram. 10,8% não sabem se participaram de pesquisa científica. 54,2% foram fotografados durante os procedimentos odontológicos e, destes, 47,1% assinaram um termo de autorização. 6,6% tiverem amostra de saliva solicitada e 66,6% destes assinaram um termo de autorização. 16,1% tiveram uma solicitação de doação dos dentes e, destes, 64,4% assinaram um termo de autorização. 61,3% não sabiam o destino do dente após a sua remoção quando a doação não foi solicitada.

Conclusões:

A maioria dos pacientes assinou o termo de consentimento para tratamento, fotografias, amostra de saliva e doação de dentes. Isso demonstra que condutas éticas perante os pacientes estão sendo seguidas pelos professores e estudantes de graduação e pós-graduação.

Palavras-Chave: bioética; ética; odontologia; pesquisa; termo de consentimento

BACKGROUND

The importance attached to ethical practice and associated informed consent varies among health professionals and is further influenced by working environments, level of knowledge, experience and societal values and beliefs (1).

Several studies have assessed the methodological/reporting quality of oral health (2-4) and examined important aspects related to conduct (5,6). Moreover, autonomy is a hugely important value, and the ability of the health professional to provide care also must be respected. This leads to the crux of the moral issues involved in setting limits to individual autonomy in health care (6-8).

One of the major challenges in bioethics has been research involving human volunteers. Historically, there was an “omission” of basic human rights, which resulted in the need for guidelines and norms on this kind of research (9).

In Brazil, guidelines and norms for research with human subjects were created. Initially, this was accomplished with Resolution 1/88 issued by the National Health Council (10) to the effect that studies should be conducted in such a way that scientific progress is not more important than people’s well-being and the protection of their rights. Later, Resolution 196/96 approved research guidelines and regulatory norms involving human subjects, and it was supported by international documents such as the Nuremberg Code and the Declaration of Helsinki, and incorporates the four basic principles of bioethics: autonomy, non-maleficence, beneficence and justice (11,12). This last resolution was improved through Resolution 466/12.

Therefore, research subjects should know their participation is voluntary and they must understand what health researchers will do and decide whether or not to give their consent to participate in a study (8,12-16). Currently, many studies are conducted in educational institutions and the research subjects are patients who need the clinical services of those institutions. However, it is important to emphasize that the research volunteer and the patient are separate and have different needs. Research subjects contribute to science interests voluntarily and patients need treatment (1,17).

Consequently, this study analyzed the ethical conduct of professors, undergraduates and graduate students through questionnaires applied to patients at the dental clinics of different dental schools.

METHODS

A questionnaire was prepared with 14 objective questions about signing informed consent, participation in scientific research, photos during treatment, requested saliva samples, requested tooth donation and information about tooth destination after removal. It was a descriptive and qualitative study carried out through data analysis.

Prior to the start of data collection, the research project was evaluated and approved by the Research Ethics Committee (CAAE nº 0043.0.138.000-09).

The research subjects were selected randomly (n=40) from three different dental schools at the University of São Paulo (the São Paulo Dental School, the Bauru Dental School and the Ribeirão Preto Dental School). The selection included patients who had finished treatment and those who were undergoing treated. In all, 120 volunteers were chosen. The participation of these research subjects was conditioned to a correct understanding of the goals and methods, as well as acceptance and signed of informed consent.

A frequency distribution (absolute and percentage values) was used for a statistical analysis of the data. The data were analyzed and distributed according to the patient’s response, as per the three different dental schools, then organized together. All the data were collected on one occasion only, because some patients finished their treatments shortly after answering the questions.

RESULTS

The results in terms of signed informed consent and participation in scientific research by patients are shown in Table 1.

Table 1 Signed Informed Consent to Treatment and Participation in Scientific Research 

The letter “N” refers to the number of patients who answered that part of the question.

Table 2 shows the patients who were photographed during dental treatment and gave their signed informed consent.

Table 2 Photos during Treatment and Signed Informed Consent 

The letter “N” refers to the number of patients who answered that part of the question.

In this table, “signed informed consent” applies to the patients who answered yes to the question about photographs.

Saliva sample requested and signed informed consent are shown in Table 3.

Table 3 Saliva Sample Requested and Signed Informed Consent 

The letter “N” refers to the number of patients who answered that part of the question.

In this table “signed informed consent” applies to the patients who said yes to the question about a saliva sample.

Table 4 shows tooth donations requested from the patients and the informed consent signed by them.

Table 4 Tooth Donation Requested and Signed Informed Consent 

The letter “N” refers to the number of patients who answered that part of the question.

In this table, “signed informed consent” applies to the patients who said yes to the question about tooth donation.

Finally, Table 5 shows tooth destination reported to patients, after removal, when donation was not requested.

Table 5 Tooth Destination after Removal, when Donation was not Requested 

The letter “N” refers to the number of patients who answered that part of the question.

DISCUSSION

It is observed that most patients had given signed informed consent, which is very important information. The patient and his/her rights are being respected, as required by Resolution CNS 466/12 (11), since it is necessary to show all procedures, risks and benefits, which must be written in language that is accessible and understandable to the research subject (1,13-16,18). It should be noted that the person’s autonomy should be respected so he/she can make decisions that might affect their life (1,13,16,18).

Although more than half of the patients had given their signed informed consent, those who did not remember are a cause for concern. However, the bias in not remembering about signing informed consent can be explained by the fact that subjects might not understand the contents of the term (13,18-20). Best practice already obliges researchers to comply with a range of legal and ethical obligations, with a particular focus on informed consent and research transparency (6,15,16,18,21).

Regarding participation in scientific research, despite the fact that only a few patients did not know if they had participated, it is something that should not happen. This must be explained to patients who are invited to participate in research voluntarily, including informed consent. If so, they would remember their decision to participate in research or their refusal to do so (6,12,13,18,22).

The research subject is a person who agrees to attend voluntarily, to contribute to science interests, and to look for progress and an improvement in the research field. The patient is seen as a person who requires care and treatment, and this need must be satisfied by the responsible professional, regardless of acceptance to participate in scientific studies (14,17,18,22).

The reasons for taking part (or not) in clinical trials have been reported in another study (23). A major theme emerging from the analysis was the extent to which people said they took part because they anticipated some kind of personal benefit and this was their primary motivation. Others expressed more mixed reasoning, citing both personal benefits and helping others or medical science. In many of these cases, helping others was presented as a secondary reason, while a smaller number said it was their primary motivation and personal benefit was secondary. Very few people mentioned helping medical science or benefiting others as their only reason (24).

The number of patients who were photographed during treatment and had not given their signed informed consent was very similar to those who had given their signed informed consent. In most parts of the developed world, written consent is usually obtained for medico-legal purposes prior to any medical procedure, including photography (25). Patients need to be informed of the purpose for which their photographs are to be used (26). In medical practice, privacy of the individual patient and confidentiality of patient information should never be violated. Indiscriminate use of patients’ photographs violates the ethical principle of ‘respect for persons’ (25). A few patients had been requested to give a saliva sample and been asked for a tooth donation, and the majority of them had signed an authorization to that effect. This information is important because the patients had given a body part or a sample and had consented to do so, in writing, according to Resolution CNS 466/12 (11,27). A number of lawsuits concerning the use of human tissue in research emphasize the central importance of the donor’s informed consent (21,28). The use of teeth and saliva as biological samples of human origin must comply with legislation and ethical rules (27,28,29,30). Acceptability, as measured by the proportion of samples collected, varied by sample type. Saliva was easily accessed and given by all participants after having given their informed consent in writing (31).

More than half of the patients did not know the destination of the tooth after removal, when donation is not requested. This probably occurs due to a lack of information about the tooth being considered an organ of the body (27,28,30). Research transparency is relevant, since it means participants feel their autonomy is respected and their interests are being represented throughout the research process (21).

Another study considered it discouraging that, despite in-depth information sessions and the consent process, 4-12% of the participants, depending on the type of sample, gave it because they thought it was required. It is recommended that consent forms include a section where participants can indicate the sampling methods they consent to. Since the consent form is signed at the beginning of the study, verbal confirmation as to which samples the participant is agreeing to at each visit is also recommended. This should be documented, in writing, in clinical notes or other source documents. There currently is a clinical trial with these added precautions. The authors plan to compare participants’ reasons for agreeing to provide specimens and to determine if this additional step has improved their understanding of the study requirements (31).

CONCLUSIONS

The majority of the patients gave signed informed consent for treatment, photos, saliva samples and tooth donations. This demonstrates that professors, undergraduates and graduate students were working ethically in the dentist-patient relationship, which is very important for all the procedures done in dentistry.

ACKNOWLEDGMENT

The authors wish to thank the University of Sao Paulo for the financial support it provided through scientific initiation scholarships given by the Teaching with Research Project. They also wish to thank the dental schools for giving them free access to their campuses during the data collection process.

REFERENCES

1. Ochieng J, Ibingira C, Buwembo W, Munabi I, Kiryowa H, Kitara D, et al. Informed consent practices for surgical care at university teaching hospitals: a case in a low resource setting. BMC Med Ethics [Internet]. 2014;15(1):40. Available from: http://www.biomedcentral.com/1472-6939/15/40Links ]

2. Pandis N, Polychronopoulou A, Madianos P, Makou M, Eliades T. Reporting of research quality characteristics of studies published in six major clinical dental specialty journals. J Evid Based Dent Pract [Internet]. Elsevier Ltd; 2011 Jun;11(2):75-83. Available from: http://dx.doi.org/10.1016/j.jebdp.2010.11.026Links ]

3. Seehra J, Wright NS, Polychronopoulou A, Cobourne MT, Pandis N. Reporting quality of abstracts of randomized controlled trials published in dental specialty journals. J Evid Based Dent Pract [Internet]. Elsevier Ltd; 2013 Mar;13(1):1-8. Available from: http://dx.doi.org/10.1016/j.jebdp.2012.11.001Links ]

4. Pandis N, Polychronopoulou A, Eliades T. An assessment of quality characteristics of randomised control trials published in dental journals. J Dent [Internet]. Elsevier Ltd; 2010 Sep;38(9):713-21. Available from: http://dx.doi.org/10.1016/j.jdent.2010.05.014Links ]

5. Saltaji H, Armijo-Olivo S, Cummings GG, Amin M, Flores-Mir C. Methodological characteristics and treatment effect sizes in oral health randomised controlled trials: Is there a relationship? Protocol for a meta-epidemiological study. BMJ Open [Internet]. 2014 Feb 25;4(2):1-7. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3939646&tool=pmcentrez&rendertype=abstractLinks ]

6. Zaror Sánchez C, Muñoz Millán P, Espinoza Espinoza G, Vergara González C, Valdés García P. Enseñanza de la bioética en el currículo de las carreras de odontología desde la perspectiva de los estudiantes. Acta Bioeth. 2014 Jun 1;20(1):135-42. [ Links ]

7. Naidoo S, Vernillo A. Ethical and legal issues on HIV testing, policy and the practice of dentistry. J Forensic Odontostomatol [Internet]. 2012 Dec;30(2):7-16. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23474504Links ]

8. Assumpção C De, Pinto N da S, Velarde LGC, Nascimento OJM do, Olej B. Compreensão do termo de consentimento em pesquisa clínica. Rev Bioética [Internet]. 2016 Apr;24(1):184-94. Available from: http://dx.doi.org/10.1590/1983-80422016241120Links ]

9. Breault JL. Bioethics in practice - a quarterly column about medical ethics. Ochsner J [Internet]. 2013;13(4):481-2. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25829872Links ]

10. Brasil. Ministério da Saúde, Conselho Nacional de Saúde [Internet]. Resolução no 001 de 13 de junho 1988, Diário Oficial da União, June 14, 1988, pp. 10.713 to 10.718. Available from: http://conselho.saude.gov.br/resolucoes/1988/Reso01.docLinks ]

11. Brasil. Ministério da Saúde, Conselho Nacional de Saúde [Internet]. Resolução no 466 de 12 de dezembro de 2012, Diário Oficial da União No. 12 Junio 13, 2013-Seção 1, pg. 59. Available from: http://conselho.saude.gov.br/resolucoes/2012/Reso466.pdfLinks ]

12. American Dental Association. Principles of ethics and code of professional conduct [Internet]. Chicago, Illinois; 2012. Available from: http://www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfLinks ]

13. Reis Pessalacia JDR, Ribeiro CR de O, Massuia D. Themes and situations that cause embarrassment among participants in research in which questionnaires or interviews are used. Investig y Educ en Enfermería [Internet]. 2013;31(1):70-7. Available from: http://www.scielo.org.co/scielo.php?script=sci_abstract&pid=S0120-53072013000100009&lng=en&nrm=is.&tlng=ptLinks ]

14. Rubinstein; YR, Karp; B, Lockhart; N, Grady; C, Groft; SC. Informed consent template for patient participation in rare disease registries linked to biorepositories. Rare Dis Orphan Drugs. 2014;1(2):69-74. [ Links ]

15. Nishimura A, Carey J, Erwin PJ, Tilburt JC, Murad MH, McCormick JB. Improving understanding in the research informed consent process: a systematic review of 54 interventions tested in randomized control trials. BMC Med Ethics [Internet]. 2013;14(1):28. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=3733934&tool=pmcentrez&rendertype=abstractLinks ]

16. Souza MK, Jacob CE, Gama-Rodrigues J, Zilberstein B, Cecconello I, Habr-Gama A. The written informed consent form (WICF): factors that interfere with acceptance. Arq Bras Cir Dig [Internet]. 2013;26(3):200-5. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=emed12&NEWS=N&AN=24190378Links ]

17. Weisberg DF. Science in the service of patients: Lessons from the past in the moral battle for the future of medical education. Yale J Biol Med. 2014;87(1):79-89. [ Links ]

18. Rillo AG. Consentimiento informado: aspectos éticos y legislación en la odontología. Humanidades Médicas. 2013;13(2):393-411. [ Links ]

19. Naanyu V, Siika A, Some F. “I understood…but some parts were confusing and hard to grasp”: Patients′ perception of informed consent forms and clinical trials in Eldoret, Kenya. Perspect Clin Res [Internet]. 2014;5(1):20-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/4375770Links ]

20. Lobato L, Gazzinelli MF. O Consentimento Informado nos países em desenvolvimento é realmente autônomo?: Um estudo descritivo com participantes de um ensaio clínico sobre Helmintoses. Acta Bioeth [Internet]. 2015 Jun;21(1):127-36. Available from: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=S1726-569X2015000100016&lng=en&nrm=iso&tlng=enLinks ]

21. McWhirter RE, Nicol D, Chalmers D, Dickinson JL. Body ownership and research. J Law Med [Internet]. 2013 Dec;21(2):323-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24597380Links ]

22. Guimarães NS, Greco DB, Fausto MA, Kakehasi AM, Guimarães MMM, Tupinambás U. Prevalência e motivos para recusar participação em pesquisa clínica. Rev Bioética [Internet]. 2016 Aug;24(2):286-91. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1983-80422016000200286&lng=pt&nrm=iso&tlng=enLinks ]

23. Locock L, Smith L. Personal benefit, or benefiting others? Deciding whether to take part in clinical trials. Clin Trials [Internet]. 2011 Feb 1;8(1):85-93. Available from: http://ctj.sagepub.com/cgi/doi/10.1177/1740774510392257Links ]

24. Locock L, Smith L. Personal experiences of taking part in clinical trials - A qualitative study. Patient Educ Couns [Internet]. Elsevier Ireland Ltd; 2011 Sep;84(3):303-9. Available from: http://dx.doi.org/10.1016/j.pec.2011.06.002Links ]

25. Adeyemo WL, Mofikoya BO, Akadiri OA, James O, Fashina AA. Acceptance and Perception of Nigerian Patients to Medical Photography. Dev World Bioeth [Internet]. 2013 Dec;13(3):105-10. Available from: http://doi.wiley.com/10.1111/j.1471-8847.2012.00328.xLinks ]

26. Carvalho GD de, Freitas KMS de, Cançado RH, Valarelli FP, Carvalho EMD de, Portes AS. A validade ética e legal das fotografias digitais na Ortodontia. Rev Ortod SPO. 2014;47(2):171-6. [ Links ]

27. Louzada LN, Jorge RC, Silva K dos S, Pacífico R dos SL, Dantas FF de P, Novaes SEA, et al. Banco de Dentes Humanos: ética a serviço do ensino e da pesquisa - a experiência da Faculdade de Odontologia da UERJ. Interagir pensando a extensão [Internet]. 2016 Mar 3;(20):67-79. Available from: http://www.e-publicacoes.uerj.br/index.php/interagir/article/view/21857Links ]

28. Gomes GM, Gomes GM, Pupo YM, Gomes OMM, Schmidt LM, Kozlowski Junior VA. Utilização de dentes humanos: aspectos éticos e legais. Rev Gaucha Odontol. 2013;61:477-83. [ Links ]

29. Le Breton A, Hervé C, Pirnay P. Information and consent in dental care associated with biomedical research. Santé publique [Internet]. 2013;25(6):803-12. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=medl&NEWS=N&AN=24451426Links ]

30. Felipe EF, Costa GBM da, Jank Júnior N, Costa JA da. Aspectos éticos da obtenção de dentes por estudantes de uma graduação em Odontologia. Rev Bioética . 2014;22(1):171-5. [ Links ]

31. Omosa-Manyonyi G, Park H, Mutua G, Farah B, Bergin PJ, Laufer D, et al. Acceptability and Feasibility of Repeated Mucosal Specimen Collection in Clinical Trial Participants in Kenya. Jaspan HB, editor. PLoS One [Internet]. 2014 Oct 31;9(10):e110228. Available from: http://dx.plos.org/10.1371/journal.pone.0110228Links ]

PARA CITAR ESTE ARTÍCULO / TO REFERENCE THIS ARTICLE / PARA CITAR ESTE ARTIGO: Tonin LO, Santos LF, Queiroz CL, Pereira JGD & Silva RHA. Ethical Conducts of Professors, Undergraduates and Graduate Students: The View of Dental School Patients. Pers. Bioét. 2017;21(1): 14-22. DOI: 10.5294/pebi.2017.21.1.2

Received: September 22, 2016; Revised: November 28, 2016; Accepted: February 20, 2017

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