- The four pillars are autonomy, beneficence, non-maleficence and justice. Each binds you unless another outweighs it in this case, so none wins automatically.
- Examiners hear the list all day. Marks go to the weighing: which two pillars clash, which one gives way, and why.
- Autonomy is mainly a right to refuse. A patient can turn down a root filling, but a request for an extraction is weighed, not obeyed.
- Weigh with four questions: capacity, reversibility, urgency and who else is affected. Then decide, and say what would change your mind.
- The GDC's nine principles carry the same ideas: patients' interests first, valid consent, fair treatment. Quote one where it fits, never as a list.
What the examiner is really testing
The four pillars come from Beauchamp and Childress's Principles of Biomedical Ethics, first published in 1979. Raanan Gillon championed them in the BMJ in 1994. They are not law and not a ranking. Each is a prima facie duty: it binds you unless another duty outweighs it in this case.
Every candidate can recite the list. The marks go to the next step: spotting the two pillars that collide, deciding which gives way, and saying why. Four definitions in a row describe the problem. They don't solve it.
The four pillars in the dental chair
- Autonomy: an adult with capacity decides what happens to their own mouth. Example: a patient declines the root filling you recommend.
- Beneficence: act for the patient's good, judged by their values as well as yours. Example: a plan that fits their budget and diary, not just the textbook ideal.
- Non-maleficence: cause no harm that the benefit can't justify. Drills, needles and forceps all harm. Crowning healthy teeth purely for looks is hard to justify.
- Justice: be fair between patients, including those not in the room. Example: one emergency slot and three people ringing in pain.
The GDC says the same thing
Dentists are judged against the GDC's Standards for the Dental Team, in force since 2013. Its nine principles carry the pillars in professional language. Quoting one where it fits shows you know the rules dentists actually work to.
- Principle 1, put patients' interests first: beneficence and non-maleficence. Standard 1.7 adds that this comes before any financial or personal gain.
- Principle 3, obtain valid consent: autonomy, with all the relevant options and their possible costs explained.
- Standard 1.6, treat patients fairly, as individuals and without discrimination: justice.
- Check before the day: from June to August 2026 the GDC consulted on replacing the nine with four principles. As of October 2026, the nine still apply.
How to weigh two pillars that clash
Turn each pillar into a sentence about this patient, then weigh. "Respect her autonomy" becomes "don't do a root filling she has refused". A handful of facts usually decides it.
- Capacity: can this person make this decision now? Under the Mental Capacity Act 2005, an unwise choice is not proof that they can't.
- Refusing or demanding: a refusal by an adult with capacity binds you. A demand doesn't. In Burke (2005) the Court of Appeal said autonomy can't force a treatment.
- Reversibility: an extracted tooth or drilled enamel can't be put back, so irreversible steps need more care.
- Urgency and other people: what does waiting cost, and whose care shrinks if you say yes?
Worked example: the restorable molar
A 52-year-old with capacity has a painful lower molar that a root filling and crown could save. She wants it out. A root filling failed on her before and she can't take time off. On the NHS in England, a course with a crown is band 3 (£332.10 from April 2026); an extraction is band 2 (£76.60).
- Autonomy: she may refuse the root filling. Your job is to check she understands what losing the tooth means now and later.
- Beneficence: her good includes her time, her money and her past experience, not just the ideal tooth.
- Non-maleficence: extraction is a harm, but a limited one, and leaving the painful tooth untreated is worse.
- Justice: a long root filling uses scarce NHS time, but that must never decide her care.
- Decision: extraction is a reasonable option for her, so I'd do it once she understands, and record her reasons in her own words.
- Boundary: if the tooth were healthy and pain-free, I'd decline, explain why and offer a second opinion.
How this comes up on the day
- "What are the four pillars of ethics?" — one line and one dental example each, then say the real skill is weighing them.
- "A patient wants a tooth out that you could save." — separate refusing from demanding, weigh all four, decide, then give your boundary.
- "A nervous patient refuses X-rays but wants a filling." — explore the fear and explain why it matters, then respect a refusal and do only what is safe.
- "Is it ever right to override a patient's wishes?" — only if they lack capacity or others face serious harm, never just because you disagree.
- "One emergency slot, three patients in pain. Who gets it?" — justice: decide by clinical need, with a rule you could explain to all three.
The words to use
- Prima facie duty
- A duty that binds you unless a stronger duty outweighs it in the case in front of you. All four pillars work like this, so none wins automatically.
- Capacity
- The ability to make a particular decision at a particular time: understand, retain, use or weigh the information, and communicate a choice (Mental Capacity Act 2005).
- Paternalism
- Overriding someone's choice for their own good. Recommending treatment is beneficence; imposing it on an adult with capacity who has refused is paternalism, and unlawful.
- Opportunity cost
- What else the same money or chair time could have done. In NHS dentistry, a long appointment for one patient is time another patient does not get.
Model answer
“What are the four pillars of medical ethics, and does any one of them matter most in dentistry?”
They're autonomy, beneficence, non-maleficence and justice. Autonomy means an adult with capacity decides what happens to their own mouth, so if someone turns down a root filling, that's their call. Beneficence is acting for the patient's good, and I'd add, good as they see it. That might mean a plan that fits their budget rather than the textbook ideal. Non-maleficence is not causing harm the benefit can't justify. That matters a lot in dentistry, because almost everything we do, drilling, injecting, extracting, does some harm. It's why crowning healthy teeth just for looks is so hard to defend. Justice is fairness, including to people who aren't in the room, like someone who can't get an NHS appointment at all. On which matters most, I don't think any of them wins automatically. They're weighed case by case. There is a pattern, though. When an adult with capacity refuses treatment, autonomy almost always wins. It's much weaker the other way round. If a patient asks me to take out a tooth I could save, that's a request I weigh, not an order. If extraction is a reasonable option for her, I'd do it once I'm sure she understands what she's losing. If the tooth were healthy, I'd say no and offer a second opinion. So for me, the pillars are a way of spotting which two duties are pulling against each other. The real skill is saying which one gives way, and why.
Sources 8
- Principles of biomedical ethics, first edition (Beauchamp and Childress): library record — US National Library of Medicine, 1979
- Medical ethics: four principles plus attention to scope (Gillon) — BMJ, 1994-07
- Standards for the Dental Team (effective 30 September 2013) — General Dental Council, 2013-09
- Standards for the Dental Team, Principle 1: put patients' interests first (standards 1.6 and 1.7) — General Dental Council
- Consultations and responses: a new Framework for Professionalism (2 June to 31 August 2026) — General Dental Council, 2026-10
- Mental Capacity Act 2005, section 1: the principles — legislation.gov.uk
- R (Burke) v General Medical Council [2005] EWCA Civ 1003 — Court of Appeal (Find Case Law, The National Archives), 2005-07
- NHS (Primary Dental Services and Dental Charges) (Amendment) Regulations 2026, SI 2026/265: explanatory note (band charges) — legislation.gov.uk, 2026
Content reviewed 2026-10-24