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The "golden rule" also supplies an ethical guidepost- treating others as one would wish to be treated. If age, gender, or other issues make that transference awkward for patient or practitioner, then the dentist can put the decision in the perspective of what level of care would be provided if the patient were his or her own grandparent, parent, sibling, or child, all the while remembering to put the needs of the patient uppermost in the decision-making process. The clinician should avoid preconceived ideas as to what a particular class of individuals, such as the elderly, desire, need, or are due. In addressing the very concerns first voiced in ancient times, the Code articulates acceptable professional behavior in upholding patient autonomy, minimizing harm through nonmaleficence, maximizing patient welfare through beneficence, promoting the fair and equal treatment of patients or justice, and maintaining honesty through the principle of veracity. Although the Code states that violations of its provisions may result in disciplinary action, its practical effect is generally limited to standing or membership in the organization itself. Fortunately, in many cases the law has become a substitute for what may otherwise have been lost. Each of the five ethical areas covered by the Code is addressed by the legal system. As will be shown, law, ethics, and morals require a dentist to do what the patient desires, subject to the limitations imposed by law, morals, and ethics. Patient records that contain diagnoses and tests, a well thought out and clearly recorded treatment plan, written informed consent forms signed by the patient, and coherent progress notes can be seen as excellent evidence of professional competency. Clinicians may also experience ethical dilemmas as seen in the accompanying In Clinical Practice box. Preparedness can help the dentist avoid having a suit filed, effectively defend against any suit brought, and minimize compensatory damages in those rare instances when the patientplaintiff prevails. The Most Common Types of Disciplinary Actions Initiated by State Dental Boards in the United States In 2002, 1928 disciplinary actions against dentists were reported by U. Approximately 17% of the cases resulted in probation, whereas 16% resulted in reprimand or censure. Remedial education and suspension each accounted for 10% of the disciplinary actions taken. About 4% of the cases resulted in voluntary resignation or retirement, and another 4% resulted in the dentist receiving treatment for substance abuse. The remaining disciplinary actions included: license revocation, practice restriction, controlled license sanctions, and medical or psychological evaluation or treatment. Because our legal system is adversarial in both divisions, attorneys represent clients, acting as advocates who enter facts into evidence and argue the law on behalf of their clients. Commonly, a jury of citizens is impaneled to be the trier of fact, that is, to rule on which party has proved its case. Judges rule on all matters concerning the applicable law and also on the facts in cases not heard by a jury. Civil law governs the private legal relationships between two or more parties, such as in cases of negligent actions or tort law, in other words, malpractice. Criminal law operates when a person commits a wrongful act against society or the public, such as driving while under the influence of alcohol. A nonsanctioned act directed toward an individual, such as an assault or battery, may also be a crime. A dental practice may interact with criminal or civil law or even, in unusual cases, both-a dentist could be charged criminally for battery and could be held liable for damages in the same incident. Administrative law, a smaller third division of law, governs the state and federal regulatory areas, such as professional licensing and rules for U. In Clinical Practice An Ethical Dilemma Upon graduation from dental school more than 20 years ago, some classmates kept in close touch as our practices were beginning. When the patient had presented for his first examination, my friend noticed a lesion on the upper lip that he suspected might be cancerous. He again pointed out the extreme urgency of seeking prompt and thorough intervention. He felt strongly that he should intervene, but the patient was adamant in refusing the recommended treatment, even though it might be lifesaving. After the second visit, my friend concluded that he could no longer ethically treat this individual. One could argue that refusing to provide further care could only make matters worse because by the time the patient had found a new dentist, the melanoma might be too advanced for effective treatment should the patient change his mind. Although no answer is correct per se, this example does not seem to offer many easy choices. First, the defendant must owe a duty to the plaintiff and second, the defendant must breach that duty.

She has conducted field work in Afghanistan, Burma, Colombia, Mexico, Burma, Brazil, India, and Morocco. He has led projects on topics such as the security implications of climate change, diverse cultures of hackers, and the global narcotics trade. Gilman spent 6 years leading competitive intelligence and product marketing teams at enterprise software companies. He is the author of Mandarins of the Future (The Johns Hopkins University Press, 2003) and coeditor of Deviant Globalization (The Continuum International Publishing Group, 2011), which explores how globalized black market economies are challenging traditional state authority. Gilman is also coeditor of Humanity, an international journal of human rights, humanitarianism, and development. Jesse Goldhammer is a partner at the Monitor Group and the firm Monitor 360, where he helps public- and private-sector clients engage in strategic, analytic, organizational, and institutional transformation. Goldhammer has spent the past 20 years bringing together unique people, ideas, and approaches to devise lasting and effective solutions to vexing problems. These solutions include developing novel analytic approaches to understand and reframe client challenges, using human networks to leverage alternative and unorthodox perspectives, and designing training programs to propagate new strategies and tradecraft. Goldhammer is also an expert in scenario planning, has taught scenario-planning courses, and published "Four Futures for China Inc. Goldhammer is the author of the Headless Republic (Cornell University Press, 2005) and coeditor of Deviant Globalization (The Continuum International Publishing Group, 2011). Patrick Radden Keefe is a staff writer at the New Yorker and fellow at the Century Foundation where his research and writing focus on transnational crime, international security, and foreign affairs. He is the author of the Snakehead: An Epic Tale of the Chinatown Underworld and the American Dream (Knopf-Doubleday, 2009) and Chatter: Uncovering the Echelon Surveillance Network and the Secret World of Global Eavesdropping (Random House, 2005), along with numerous book chapters on espionage, national security, and illicit networks. From 2010 to 2011, he served as a special advisor in the Office of the Secretary of Defense for Policy where he focused on crime, corruption, and rule-of-law issues. Lindholm plays a strategic role in activities related to hybrid/transnational threats, including threat finance, illicit networks, and anti-money-laundering issues. She has also worked as country manager for 271 About the Contributors Middle East and North Africa regions for the U. Trade and Development Agency; special assistant to the Under Secretary of State for Economic, Business, and Agricultural Affairs; advisor for international economic policy at the National Economic Council; and senior policy advisor to a Congressman, responsible for financial services, national and homeland security, and foreign affairs. Lindholm was vice president for policy at Business Executives for National Security, where she worked with Treasury, the Defense Department, Drug Enforcement Administration, combatant commands, and the private sector to develop solutions and share information on potential vulnerabilities in the financial services sector. Luna helps coordinate diplomatic initiatives on national security that disrupt and dismantle transnational criminal networks. Naнm has written extensively on international economics and global politics, economic development, and the unintended consequences of globalization including books such as Illicit: How Smugglers, Traffickers, and Copycats Are Hijacking the Global Economy (Doubleday, 2006). He is the chairman of the board of both the Group of Fifty (G-50) and Population Action International and a member of the board of directors of the National Endowment for Democracy and the International Crisis Group. He has invented disruptive technologies that protect billions of products and documents from counterfeiting and tampering. Picard has written numerous papers and patents on document security, anticounter- 272 About the Contributors feiting, artificial intelligence, and illicit trade, and is a frequent speaker on anticounterfeiting technologies. Picard and his company were selected as a World Economic Forum Technology Pioneer. Since 2009, he has been a member of the World Economic Forum Global Agenda Council on Illicit Trade, and is also a member of the Evian Group. Realuyo is an assistant professor of national security affairs in the Center for Hemispheric Defense Studies at the National Defense University. She is an expert on geopolitical risks in the 21st century, global supply chains, international financial systems, terrorist financing, and money laundering. She is a member of the Council on Foreign Relations, International Institute for Strategic Studies, Women in International Security, and Professional Risk Managers International Association. Louise Shelley is a professor in the School of Public Policy at George Mason University. She is an expert on the relationship among terrorism, organized crime, and corruption as well as human trafficking.

When mouse embryos were exposed to a priming dose of about 10 mGy and evaluated for chromosomal aberrations or defects in development induced by a challenge dose several hours later, the results were highly variable for the induction of an adaptive response (Muller and others 1992; Wojcik and others 1992; Wolff 1996; Wang and others 1998). Adaptation not only decreases the frequency of mutants induced by a challenge dose but also appears to alter the types of mutants. The adaptation phenomenon appeared to involve a protein kinase C signaling pathway. In addition, the lack of an adaptive response in a tumorigenic variant, clone 6110, and restoration of the adaptive response obtained by introducing human chromosome 11 (five other chromosomes had no effect) further suggested that interference of signaling pathways may alter adaptive responses in malignant cells. The observation (Broome and others 2002) that a priming dose as low as 1 mGy induced an adaptive response in a nontransformed human fibroblast cell line for micronuclei induced by a challenge dose of 2 Gy has to be confirmed for other systems and end points, such as mutation induction. Also, the large variation in adaptive response for radiation-induced micronuclei in human lymphoblastoid cell lines must be considered (Sorensen and others 2002). Most important, the adaptive response has to be demonstrated for both priming and challenging doses in the lowdose range <100 mGy, and an understanding of the molecular and cellular mechanisms of the adaptive response is essential if it is to have relevance for risk assessment. Studies of adaptation for malignant transformation in vitro provide conflicting information and might not be relevant to malignant transformation in vivo. Closed symbols represent results in cells in G1 preirradiated with 20 mGy of X-rays 5 h before graded doses of acute radiation. Open symbols represent results in cells in G1 given graded doses of acute radiation only. Statistical errors are standard errors of the mean based on variation in the number of recovered colonies in irradiated dishes (this does not include propagation of error in plating efficiency of nonirradiated controls). These transformation results, however, contrast with results in mouse C3H 10T1/2 cells that were exposed in plateau phase to a challenge dose of 4 Gy 5 h after a priming dose of 100 or 670 mGy. Furthermore, the priming dose of 100 or 670 mGy caused an increase by a factor of 2­5 in the transformation frequency relative to the frequency of about 3 Ч 10­4 observed for nonirradiated cells. When the same group of investigators exposed the same C3H 10T1/2 cells in plateau phase to priming doses of 1, 10, or 100 mGy, the neoplastic transformation frequency was lower by a factor of 3­ 4 than the spontaneous frequency (Azzam and others 1996). The reduction was observed only when the cells were trypsinized and replated 24 h after irradiation for the transformation assay; trypsinization and replating immediately after irradiation did not alter the frequency. Similar results have been reported by Redpath and coworkers (Redpath and Antoniono 1998; Redpath and others 2001): the malignant transformation frequency was reduced by about half when human hybrid cells approaching confluence were trypsinized and replated 24 h after a priming dose of 10 mGy; again, no statistically significant reduction in transformation frequency was observed when the cells were trypsinized and replated immediately after irradiation. The validity of extrapolating any of the results from in vitro neoplastic transformation systems to malignant transformation in vivo may be questioned for the following reasons. First, the effects associated with variations in time of trypsinization and replating after irradiation must be understood (Schollnberger and others 2002). Second, the measured neoplastic transformation frequency depends on both the density of viable cells plated (Bettega and others 1989) and the number of generations before the cells become confluent (Kennedy and others 1980). Third, when priming doses of 1­100 mGy resulted in a decrease in the neoplastic transformation frequency, the spontaneous transformation frequency was unusually high in one case (Azzam and others 1994), and a Hela X skin fibroblast human hybrid cell system was used in the other (Redpath and Antoniono 1998). Fourth, studies of malignant transformation in immortalized (already-transformed) cell lines may have little relevance to malignant transformation of normal nonimmortalized cells, especially in vivo, where complex interactive processes can occur (Harvey and Levine 1991; Kamijo and others 1997). For several mammalian cell lines in culture, adaptive responses for cell lethality after doses of 200­600 mGy (Marples and Joiner 1995; Joiner and others 1996; Marples and Skov 1996; Wouters and others 1996; Skov 1999) and for enhanced removal of thymine glycols after a dose of 2 Gy (Le and others 1998) have been observed 4­6 h after a priming dose of 200 mGy. In fact, regulation of repair and cell cycle progression may be achieved by differential complex formation (Eckardt-Schupp and Klaus 1999). The sensors for these fast responses are in membranes, and they initiate signal transduction by several cascades of protein kinases (Eckardt-Schupp and Klaus 1999) that may involve reactive oxygen intermediates (Mohan and Meltz 1994; Hoshi and others 1997). There is much variability and heterogeneity in the ability to induce adaptive responses that usually require a priming dose of 10­200 mGy and a large challenge dose of 1­2 Gy. Challenge doses of this magnitude probably have little relevance to risk assessment for low radiation doses of 1­ 100 mGy. Furthermore, the molecular pathways associated with the phenomenon have not been delineated. The ability to induce an adaptive response appears to depend on the genotype (Wojcik and others 1992), which may relate to genetic variation reported for radiation-induced transcriptional changes (Correa and Cheung 2004). In fact, the effect of the genotype on the adaptive response has been demonstrated most conclusively in Drosophila melanogaster (Schappi-Bushi 1994). A priming dose has been reported to reduce chromosomal damage in some chromosomes and increase it in others (Broome and others 1999).

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