Since its inception as a dental specialty in 1958 (1,2), the practice of oral and maxillofacial surgery in our milieu has changed over the years. Changes in the economic, social environment and in the nature of the health care system have contributed to the emergence of de-professionalizing forces that currently challenge ethics and professionalism in clinical practice (3). Oral and maxillofacial surgeons are obliged to know and to do what ought to be done, that is, to honor the core values and principles embedded in our professional code of ethics (4). However, training flaws, conflicts of interest, weak regulatory bodies, limited practice opportunities, and a commercialized health care market can elicit potential challenges that erode professional behavior, and thus compromise the reputation and integrity of the specialty (3,5,6). In these circumstances, with a complex present and a murky future, becoming aware of and reaffirming our ethical and professional responsibilities with trainees, patients, colleagues, and society is of paramount importance. This paper is designed to provide oral and maxillofacial surgeons with a broad outline of the common ethical problems that they are likely to encounter in their daily practice.

During our career, professionalism and ethics are inextricably intertwined. Both form part of the essence and daily practice of oral and maxillofacial surgery. As specialists we are distinguished by our specialized training, body of knowledge, and technical skills, as well as our commitment to provide special service to others. Likewise, as members of a regulated learned profession we are committed and obliged by law to specific standards that must be acknowledged and demonstrated in our behavior and performance. These specific obligations comprise our deontological framework and moral responsibilities, namely the ¨ethos¨ of our profession. Therefore, ethics is the conscious and unconscious application of the standards that should guide our professional decisions about the right thing to do in a specific situation (4-8).

The analysis of some contemporary ethical and professional challenges faced by oral and maxillofacial surgeons in clinical practice, and that are worthy of their review can be addressed based on Beauchamp and Childress’ four prima facie moral principles of biomedical ethics –autonomy, beneficence, nonmaleficence, and justice-. These principles are embedded in our code of conduct and, as comprehensive norms of obligation, lead to the formulation of substantives rules, which are more specific and guide our judgment and actions (4,9,10).

Certainly, a principle-driven practice is one part of ethics. The other part is the character-driven aspect, the practice of virtues, namely, to act in accordance with moral principles with a proper characteristic motive (11). Our code notes the need for acting with responsibility, honesty, and prudence. Similarly, it exhorts us to be considerate, caring, and loyal (4). These are examples of virtues that allow us to use the principles wisely and to take excellent choices and proper decisions. Principles and virtues are integrally related. Any act that breaks the connection between our moral emotions, convictions, and actions and that generates a negative reactive attitude expresses a vice (12,13). Vices such as dishonesty, arrogance, envy, and greed lead to actions (e.g., failure to fulfill responsibilities, breach confidentiality; mistreat, interact abrasively with, or exploit trainees, patients, and colleagues) that undermine and hinder principles and virtues’ moral labor and complicate the entire corpus of current ethical and professionalism concerns.

The principle of autonomy embraces respect for persons, it means self-rule or self-direct and refers to the individuals’ capacity to make choices relevant to their needs and in their best interests, free from the will of others. The right to decide based on their own beliefs and values (10). Respect for a patient’s autonomy encloses the virtue of honesty, which implies the provision of adequate and truthful information to enable patients to make the best informed and conscious decision. In this regard, respect for a patient’s autonomy is the philosophical and ethical –as well as legal- basis of the standard of informed consent (14-16).

Informed consent is the core aspect of the clinician-patient relationship. It is a continuous process, not a signature on a form; a conversation, which can involve multiple visits between the clinician and a reasonable patient –or proxy– about the nature and purpose of the treatment or surgical procedure. It includes a discussion on material risks, complications, benefits, and consequences of no treatment. Alternative treatments that may be available also should be considered. It also includes the right to refuse care. There should be the opportunity to ask questions, to discuss the treatment choice and to reflect on the decision. Finally, it should clearly indicate the ultimate decision free from manipulation or any other form of influence (14-17). Then, it is nowadays expected that oral and maxillofacial surgeons always take the time to provide patients with adequate clinical information, ensure they understand what is being informed and voluntarily authorize the procedure. However, conflicts around this concept arise as paternalism exists as a tradition and is rooted in our milieu as a salient cultural characteristic (18,19). In line with this paradigm, the principle of autonomy is still unknown and considered as foreign among practitioners and they continue to embrace an unwarranted authoritative and sometimes dismissive attitude towards patients. This way of thinking on grounds of assumptions or ideas like as specialist we are in a superior position with the power to override patients’ values and wishes, or that patients do not have the knowledge to understand or the sufficient capacity to decide what is best for them, undermines the value of informed consent and fails to implement and to fulfil a respect for autonomy-based model in clinical practice.

Over the last two decades, the way we interact with patients has become more symmetrical. It has incrementally shifted from a dominant paternalism-based model to one that advocates for respect for patient autonomy. This transition has occurred because of technological, social, cultural, legal, and ethical developments (18,20-22). The evolving nature of this new clinician-patient relationship challenges oral and maxillofacial surgeons’ commitment to beneficently guide patients to the best decision, namely to a more participatory model of autonomous choice.

As evolving moral actors, oral and maxillofacial surgeons need not only to respect and to treat patients autonomously but also to strive for and contribute to their well-being. This action falls under the principle of beneficence, which refers to the basic duty to promote and to do good while preventing and removing conditions that will cause harm (10). This endeavor indicates we shall be dedicated primarily to providing the best possible care for our patients in accordance with their values, needs, feelings, and agreed-upon treatment, namely, to act in their best interest. Beneficence entails the virtue of benevolence and of reverent consideration (21,23). Our Code of Ethics emphasizes beneficence as one of the principles governing our duties and notes as an overarching goal to provide high quality health care services to those in need and in a timely manner (1). All our efforts should be directed to accomplishing this objective in any clinical setting. In providing high quality care to patients –defined as the degree to which the treatment provided increases the likelihood of a desired health care outcome and is consistent with current professional knowledge (24)–the challenge to beneficence starts when clinicians delegate or transfer complete authority to a trainee –with or without supervision– or to an auxiliary staff member to perform a specific task or procedure that should be performed by themselves. Entrusting an inappropriate person with a complex clinical task places the patient at an unacceptable level of risk of harm. Certainly, high quality care is only achieved when a responsible clinician personally dictates care and performs the procedure.

In contrast to the principle of beneficence, whose language is one of positive requirements of action, we also are morally obligated not to inflict or to impose risk of harm to patients (9). This moral imperative is created by the principle of nonmaleficence, which is closely related to and should always be considered together with the principle of beneficence (25,26). Our code of ethics indicates the importance of not carrying out contraindicated surgical procedures or those that undermine a patient’s well-being, as well as of our responsibility related to the imposition of foreseeable risks of harms (4). In clinical practice, this statement leads to the question about the extent to which we must act to prevent harms or to reduce risks that may be likely to occur. The practice of oral and maxillofacial surgery implies per se the imposition of risk –a surgical complication that cannot be reduced or eliminated by skill, care, or technology- (27); thus, it defies the principle of nonmaleficence daily. However, law and morality recognize a standard of due care that determines whether the clinician causally responsible for the risk is legally or ethically responsible as well. Accordingly, the standard of care is a specification of the principle of nonmaleficence (7,25). Legally, the term is defined as that degree and type of care that a reasonable competent, skilled, and prudent clinician would do in the same or similar circumstances (28,29).

Over the years, the standard of care to what oral and maxillofacial surgeons are held has been guided and set by members of the specialty community by simply adopting certain conducts that have become widespread or via universal norms, clinical practice guidelines or protocols developed and issued by institutional and academic committees. The standard of care is determined on a case-by-case basis, after the fact, by expert testimony and with legislated judicial guidelines. Failure to meet the standard of care is called professional negligence and is one of the elements that needs to be proven in a malpractice lawsuit (30-32). On the other hand, ethically, standard of care is defined as the conscientious application of up-to-date knowledge, competent skill, and reasoned judgement in the best interest of the patient, honoring the autonomy of the patient (30). Challenges concerning the principle of nonmaleficence and hence both dimensions of the professional standard of care arise when clinicians lose the ability to exercise good clinical judgment, in other words, prudence, the capacity of practical wisdom (phronesis) (11,33). Good clinical judgment is necessary to determine the appropriateness of care or of a surgical procedure based on an analysis of the benefits, risks, and potential harm and on individual patient’s needs, priorities, and values, for example, to provide care that is in the patient’s best interest.

In practice, potential influences on practical wisdom are demonstrated in diverse ways: when a clinician’s personal secondary interest, usually economic, overrides the primary duty to patient well-being. When money becomes a driving force, the surgical decision-making process is fictitious; it is biased, eroded, and deviated from the expected professional standards. Likewise, the clinician who is not able to recognize the limits of his or her own professional competence and decides to proceed with cases beyond his or her knowledge or area of expertise may lead to an incident that results in great harm to a patient. Oral and maxillofacial surgeons should know a diploma does not guarantee competence and they are expected to undertake only cases and operations for which they have the appropriate knowledge or sufficient dexterity of the required technique. Whenever a clinician performs a surgical procedure that can be performed better by a more experienced surgeon the principle of “do no harm” is being compromised.

The nature of our moral agency compels oral and maxillofacial surgeons to act in line with what is due, not only to our patients but to people. Based on an Aristotelian standpoint, the formal principle of justice imposes on us the obligation to render fair, equitable, and effective treatment to everyone (11,34). In our dealing with patients, staff, trainees, colleagues, and society, fairness implies to have an unbiased disposition to treat every individual in an equivalent way, where they have the option to fulfill their desires or primary needs, in the way they wish (35). Likewise, equality refers to providing every patient the same level and quality of care regardless of non-medical or morally irrelevant aspects such as age, race, gender, educational level, and socio-economic status. A serious instance that challenges the essence of the principle of justice in clinical practice is the issue of prejudice, an attitude whose final measurable outcome is the practice of discrimination (36). The clinician who displays an unpleasant and uncaring attitude towards a poor or less educated patient, who does not take the time to examine, explain a condition or therapy and to answer the questions, who avoids provision of treatment or follow-up, who denies remedy in the event of an adverse outcome, who assigns care to trainees not yet prepared for unsupervised responsibility, who chronically offends his or her staff, who takes advantage of his or her fellows associates, who is always late or never attends rounds or meetings with students or trainees, or who mistreats, humiliate, and abuses them, exemplifies common unfair and unjust actions that show disrespect for the dignity of persons and that unreasonably lead to the provision of a lower quality of health care service and the undermining of interpersonal and professional relationships.

The essential ethical ideals of oral and maxillofacial surgery involve recognizing and honoring patients’ autonomy in informed treatment decisions, furthering patients’ own legitimate values, acting in patients' best interests, and treating people fairly. As obligatory standards they underpin the humanitarian nature of our specialty and forge the moral environment in which optimum care is provided and interpersonal relationships between clinicians, patients, and colleagues are fostered. However, it is very unfortunate that some standards have undergone a steady decline at one time.

Changes in socio-economic factors have cultivated and elicited the emergence and flourishing of a new set of academic, institutional, and self-centered values and goals focused on business, profit, wealth, image, fame, and status that have affected former social practices and epistemic conditions of moral agency. This form of moral regress has altered the way oral and maxillofacial surgery is being practiced in our milieu, resulting in instances of socially insensitive and ethically unprofessional behaviors. In the context of this new moral order there are reasons to fear that the essence of ethics and professionalism will be extinguished forever if as individuals, academics and community do not stand firm and put aside our affective ignorance (37) –i.e., choosing not to know what we can and should know; something that is morally important– and regain the acknowledgment and understanding of already existing moral concepts and ethical rules (38).