

































 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

ETHICS AND DECISION-MAKING IN THE DAILY 

PRACTICE OF ODONTOSTOMATOLOGISTS  

IN THE BOENY REGION, MADAGASCAR 
 

Rakotonirina FP1,2, Rafalimino HN¹,3, Andrianjafinoro TH¹,3, Randriamalala NC¹,4,  
Ravez L5, Ramaroson J¹. 

 

1Sub-section of Conservative Odontology Endodontic 
at the Tropical Odonto-Stomatological Institute of Madagascar (IOSTM),  
University of Mahajanga 
2 Oral Health Center, Ministry of Industrialization, Trade and Consumption 
Antananarivo, 
3University Hospital Profesora Zafisaona Gabriel Androva Mahajanga Madagascar, 
4University Hospital Joseph Dieudonné Rakotovao, Befelatanana Antananarivo 
5 Center for Bioethics of the University of Namur, Belgium 

 
 
Correspondingauthor : Rakotonirina Faliniaina Paul 
                                   IOSTM - University of Mahajanga 

--------------------------------------------------------- 
 

 

Abstract 

 According to Emmanuel et al, four conceptualmodels of medicaldecision-making 

have been identified: the paternalisticmodel,informative model, interpretative model 

and deliberative model. In Odontostomatology, the patient’srequest and the reason of 

their consultation represents a crucial factorsthat must betakenaccountwhilecreating 

the treatment plan and ensuring the intervention succes.  The aim of thisstudywas to 

determine the decision-makingused by Odontostomatologists in the BoenyRegion, in 

Mahajanga, Madagascar, during oral health care. A qualitative sociological 

descriptive cross-sectional studywascarried out among 15 Odonto-

Stomatologistspracticing in the BoenyRegion of Madagascar. It lasted 21 monthsfrom 

June 2019 to March 2021. Data werecollectedusing a formal qualitative semi-

structured interview with a pre-established open-endedquestionnairy guide. 

Theyweretranscribed in Word version ; thenprocessed and analyzedwith Microsoft 

Excel and QDA Miner software. Fifteenodontostomatologistsfrom the 

Boenyregionwereinterviewed. They chose the paternalistic model, the informative 

model and the deliberative model for decision-making. The emergence of 

shareddecision-making in the face of patient autonomy has renewed the patient-

practitioner care relationship. A patient surveywouldbe a welcome addition to 

thisstudy. 

Key words :therapeuticdecision, care relationship, ethics - patient care, Odonto-

Stomatologists - oral health 

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 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

 

I. Introduction  

Medicaldecision-makingisdefined as the intellectualact of making a 

choicebetweenseveraltherapeutic options [1]. Four conceptualmodels of 

medicaldecision-making have been proposed by Emmanuel and colleagues: the 

paternalistic model, the informative model, the interpretative model and the 

deliberative model [2]. 

The evolution of thinking on patient rights has led to a shift in decision-

makingauthorityfrom the practitioner to the patient. With the emergence of the 

Internet, and the multitude of health-relatedwebsites and other sources of medical 

information, some patients have felt more autonomous about theirhealth, 

usingpractitioners as simple“consultants” [3,4]. Currently, the concept of 

shareddecision-makingisaccepted and has legal justification [5].  

This studywasundertaken to determine the decision-making mode(s) of 

Odontostomatologists in the BoenyRegionduring oral health care. 

 

II.Methodology 

Weconducted a descriptive sociological qualitative studyamong 15 

Odontostomatologists (OS) practicing in RegionBoeny. The 

studyperiodwasconductedbetweenNovember 2019 and December 2020.  

Weincluded all generalpractitionersregisteredwith the Ordre Nationale des 

Odonto-Stomatologistes de Madagascar (ONOSM) and the Conseil de l'Ordre 

Régional des Odonto-Stomatologistes (COROS), available and present at the time of 

the interview.  

Purposive sampling wascarried out to select participants based on theirability to 

provide us with the information (in detail and depth) werequired.  

Weconducted the studyusing a formal qualitative semi-structured interview with 

an open-ended questionnaire guide, each lasting 30 minutes. To manage certain 

doubtsconcerning the answers, weopted for “triangulation” by cross-checking certain 

questions in order to compensate for a certain level of insincerity on the part of the 

stakeholders.  

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 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

The data collectedwastranscribed to Microsoft Word as soon as possible and 

copied to Microsoft Excel and QDA Miner v2.0.7, where the analyses werecarried out. 

Ethicalconsiderationsweretakenintoaccount. 

III.Résultats 

In terms of the socio-demographic profiles of Odonto-Stomatologists, the male 

genderwas the mostrepresented in ourstudy, occupying 53.3% of interviewees, and 

66.7% of all participants wereunder the age of 35. The averageagewas 32. Next, 

86.6% practiced in the City of Mahajanga, District of Mahajanga I, capital of the 

BoenyRegion. Thesepractitionershad been in practice for at least a year, 40% of 

whomwereyoungsowith no more than 5 years' experience.  

As fortheming, the decision-making process variedfrompractitioner to 

practitioner. On the one hand, somepractitionersdecided on theirownwhich 

intervention was best for their patient.  

“At first, I decide on myown, even if the patient isn'talwayssatisfied... There are 

teethwecan'textractyet, like pulpitis and/or dentinitis, so I don'textract!” 

 Sometimes, theyimposed the decision. 

“...for the patient'schoice, it'sstill us practitionerswho impose it.” 

 In this case, the patient had a passive rolesoheonly gave his agreement 

(agrément). "If the toothisstilltreatable, I'll talk to the patient about treatment, but if 

theydon'tagree, I'llsuggestthey go to anotherpractitionerwho can accepttheirchoice. 

 On the other hand, somepractitioners let the patient decide; theyonlyproposed 

the therapeuticpossibilities of the present case.  

"Yes, hedecides, I onlyofferhim the therapeuticpossibility of his case. I can't 

force him." 

 On the other hand, somedecidedtogetherwiththeir patients, but 

emphasizedwhattheyfeltwas best for the patients and steeredthemtowards the proposal 

best suited 

to their case. 

"For me, regarding the decision, weshareittogether...I propose all the 

therapeuticpossibilities and hechooses. However, I emphasize one of 

theseproposalsthat I find best for his case, without pressure or forcing."  

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 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

 Decision-makingalsovariedaccording to the clinical reality observed 

by the practitioner, the patient'specuniary situation and the influence of the employer, 

whoonlycared about the loss of earnings in theircoffers for a procedure not carried out 

with a patient. 

"As for the decision, itdepends on the context. Sometimes, werealize the 

patient'sideabecause the proceduredepends on the patient'sfinancial situation and 

availability. For example, I had a case of a patient whosetoothwasstilltreatable, but 

hementionedlack of money and lack of time for furthertreatment. In the end, wedecided 

to extract the tooth." 

"Weonly do what the patient wants, becausemy employer won't let the patient go 

home withouthavingperformed a proceduresolely for his or herownbenefit ». 

 

IV.Discussion 

 Socio-demographic profiles of practitioners 

For the socio-demographic profiles of Boenypractitioners, the 

averageagewassignificantlylowerthanthat of French practitioners at 48.8 years [6]. 

Secondly, the high proportion of odontostomatologists in the region's capital 

wasreasonable, given the increasednumber of dental practices within the city and the 

presence of infrastructure, administrative and financial services, governmental and 

non-governmentalorganizations and industrial complexes that are 

alsoconcentratedthere. This maybe due to the factthatfamily and professional living 

conditions are easierthan in the countryside. Theseinclude running water, electricity 

and the various types of medicines and dental materialsthat are fundamental to the 

smooth running of a dental practice. In addition, the predominance of 

youngpractitioners has showntheirdynamism to becollaborators in research. 

 Analyse of the theming 

The decision-making process varies frompractitioner to practitioner.  

 The paternalistic or parental model 

On the one hand, somepractitionersdecide on theirownwhich intervention is best for 

their patient. They impose the decision. In this case, the patient plays a passive role, 

giving consent only. This type of medicaldecisionis part of paternalism [2]. In a 

paternalisticrelationship, the practitionerexercisesauthoritarian power over the patient 

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 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

and decideswhatis best for him or her, like a father for hischild [7]. However, itis no 

longer current to consider the care relationship as the meeting of the conscience of the 

caregiver and the trust of the cared-for. The concept of shareddecision-making has 

been adopted and islegallyjustified [8]. Shareddecision-making" beginswith a phase of 

neutral explanation of the diagnoses made in the previous phase [9, 10]. Then, the 

varioustherapeutic options are explained, again in a neutral manner, to help the patient 

understand and weigh up the various possible options [5].  

 The informative or patient-decision model 

On the other hand, somepractitionersonlyoffer the therapeutic options available in the 

current case and let the patient decide on theirowntreatment. This is an informative 

medical model. In a consumeristrelationship (informative model), itis the patient 

whodecideswhattheywant in terms of health, with the practitionerplayingonly an 

executiverole [7]. A prominentroleisthusgiven to the expression of informedchoices by 

patients, whobecomeactors in theirownhealth [11]. 

 The disguised deliberative or paternalistic model 

Furthermore, some dental surgeons decidetogetherwiththeir patients whichprocedures 

to undertake, whileemphasizingwhattheybelieveis best for the patients and 

guidingthemtowards the mostsuitable option for their case. This represents a 

deliberativemedical model. Here, the practitioner not onlyinforms the patient of 

whatcouldbedone but, knowing the patient and hoping for the best for them, 

alsosuggestswhattheythinkshouldbedone. The practitioner and the patient engage in a 

discussion about whichmedical values the patient could and shouldultimatelypursue. 

This model may tend to resemble a disguisedform of paternalism. [12]. 

Moreover, the studyshowedthatdecision-makingalso varies according to the clinical 

reality observed by the practitioner, the patient'sfinancial situation, and the employer's 

influence. The latter, especially in private institutions, isprimarilyconcernedwith the 

loss of revenue in theircash-flow. Consideringthesethreefactors has also been 

unavoidable for Malagasy practitioners. This couldbeexplained by the deficiency of 

bioethics practice in the country. Indeed, the establishment of healthethicscommittees 

and the regularimplementation of continuingeducation on bioethics and dental 

ethicswouldbedesirable to promoteitsfield of application in Madagascar. 

 

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 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

Conclusion 

In the end, our objective has been achieved as wewere able to determine the decision-

making model(s) used by dental surgeons in the BoenyRegionduring oral care 

management. Consequently, we can inferthatthreemodels of medicaldecision-

makingproposed by Emmanuel and hiscollaborators have been employed by the dental 

surgeons in the BoenyRegion: the paternalistic model, the informative model, and the 

deliberative model. The success of the proceduredepends on a good relationship and 

shareddecision-makingwith the patient. The implementation of thisshareddecision-

makinghelpsprevent dental disputes in all aspects. Lookingahead, a study on the 

impact of decisions made beforetreatmentwith patients wouldbevaluable as a 

complement to thisstudy. 

 

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idéalismes et réalités cliniques. Paris : L’harmattan ; 2003, 104 p 

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3. Fouche G. Soins dentaires à l’étranger : Impact sur la relation chirurgien-dentiste/patient 

[Master 2, recherche en éthique]. Paris. Université Paris Descartes. 2012 

4. Fronty Y, Jordana F, Colat-Parros J, Fronty P, Sapenet M. Activités des experts judiciaires 

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 IJO- INTERNATIONAL JOURNAL OF SOCIAL SCIENCE AND HUMANITIES RESEARCH 

( ISSN 2811-2466 )                                                                           Rakotonirina Faliniaina Paul
 1* 

https://ijojournals.com/                                                            Volume 08 || Issue 03 || March, 2025 || 

ETHICS AND DECISION-MAKING IN THE DAILY PRACTICE OF ODONTOSTOMATOLOGISTS IN THE BOENY REGION, MADAGASCAR 

 

 

[cité 15 octobre 2019]. Disponible : https://nanopdf.com/download/lapproche-centree-sur-

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