ETHICS IN ORTHODONTICS
Nothing but the truth. Peter M. Greco Philadelphia, Pa
E
ric returns for his monthly adjustment, and his oral hygiene is just as poor as ever. As you retract his lips and observe the plaque accumulation that resembles yellow cottage cheese, you relive each minute of every discussion you have had with Eric and his parents regarding his need to improve his hygiene. You recall the times when you had your assistants review every plaque-control technique available, and even the time when you became so dismayed by his home care that you brushed his teeth yourself. None of those efforts has been fruitful. And Eric is no different from any of your eighthgrade patients who incessantly ask when the braces will be removed. Finally, when you can take it no more, you blurt out, “If you cleaned your teeth more effectively, you would have been done with treatment by now! Dirty teeth always slow down movement of your teeth!” There is an eerie silence in the operatory and at the next 2 chairs, as you realize what you have said. In your anger, you have blatantly lied! No question that your intent was to benefit your patient despite your deception, but is your lie justified? The health professions, specifically medicine, have modified their posture on lying to patients. Realizing the difficulty in determining a totally accurate prognosis, intending to avoid undermining a patient's faith in recovery, or merely uncomfortable in sharing bad news, doctors have occasionally lied to their patients in discussions of diagnosis and prognosis.1 Classical ethical codes, including the Hippocratic Oath, emphasize a paternalistic approach to practice based on the premise of beneficence for a patient who is ignorant of that which is best for himself. Whereas these directives emphasize protection of patient vulnerability, no code mentions veracity (truth telling).1 The physician's intent is to promote a good outcome despite the deception. Following the classical utilitarian philosophy—defining actions that provide a good outcome as “good”—the
Am J Orthod Dentofacial Orthop 2014;146:5 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2014.05.003
morality of the lie is overlooked with the intent of preserving the patient's happiness by encouraging his cure. Consider this unique feature of the medical profession. Although lying is snubbed in almost all other professions and trades, lying to protect a patient had somehow been considered to be justified. But in the early 1970s, medicine began to change its perspective on lying to patients. Veracity in hopeless cases is now preferred.1 Is lying ever justified in orthodontics? Despite our freedom from dealing with life-and-death issues, some situations arise in daily practice that can present a forum for lies. Consider the youngster with an overretained, mobile deciduous second molar in which the succedaneous tooth is diverted lingually by the retained molar. Your request for the dentist to extract the tooth has been ignored for the patient's last 3 visits. It's tempting to tell Junior that “I'm just looking” and snatch the tooth in a flash. Or that plea for a debanding date that is heard by orthodontists around the globe might initiate the temptation to provide a flippant, untruthful answer to silence the question. Lying in a clinical setting breeds mistrust between the patient and the orthodontist, can create psychological trauma, and shows disrespect for a person. Also, lying can be destructive to an orthodontist's reputation—and is morally wrong.2 Despite your best intentions, does your effort at preserving Eric's dental health justify the falsehood you blurted out about his hygiene? Ethics is rarely absolute; often two apparently conflicting ethical principles need to be weighed against one another: beneficence and veracity, in this case. But in retrospect, perhaps your further persistence regarding Eric's home care might have been the order of the day, even if it required more patience on your part. After all, few would contest that honesty is the best policy. REFERENCES 1. Brannigan MC, Boss JA. Moral theory. In: King K, Williams M, editors. Healthcare ethics in a diverse society. Mountain View, Calif: Mayfield; 2001. p. 145. 2. Rule J, Veatch RM. Dealing honestly with patients. In: Bywaters L, Harmon L, editors. Ethical questions in dentistry. 2nd ed. Chicago: Quintessence; 2004. p. 175.
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Nothing but the truth. Peter M. Greco Philadelphia, Pa
E
ric returns for his monthly adjustment, and his oral hygiene is just as poor as ever. As you retract his lips and observe the plaque accumulation that resembles yellow cottage cheese, you relive each minute of every discussion you have had with Eric and his parents regarding his need to improve his hygiene. You recall the times when you had your assistants review every plaque-control technique available, and even the time when you became so dismayed by his home care that you brushed his teeth yourself. None of those efforts has been fruitful. And Eric is no different from any of your eighthgrade patients who incessantly ask when the braces will be removed. Finally, when you can take it no more, you blurt out, “If you cleaned your teeth more effectively, you would have been done with treatment by now! Dirty teeth always slow down movement of your teeth!” There is an eerie silence in the operatory and at the next 2 chairs, as you realize what you have said. In your anger, you have blatantly lied! No question that your intent was to benefit your patient despite your deception, but is your lie justified? The health professions, specifically medicine, have modified their posture on lying to patients. Realizing the difficulty in determining a totally accurate prognosis, intending to avoid undermining a patient's faith in recovery, or merely uncomfortable in sharing bad news, doctors have occasionally lied to their patients in discussions of diagnosis and prognosis.1 Classical ethical codes, including the Hippocratic Oath, emphasize a paternalistic approach to practice based on the premise of beneficence for a patient who is ignorant of that which is best for himself. Whereas these directives emphasize protection of patient vulnerability, no code mentions veracity (truth telling).1 The physician's intent is to promote a good outcome despite the deception. Following the classical utilitarian philosophy—defining actions that provide a good outcome as “good”—the
Am J Orthod Dentofacial Orthop 2014;146:5 0889-5406/$36.00 Copyright Ó 2014 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2014.05.003
morality of the lie is overlooked with the intent of preserving the patient's happiness by encouraging his cure. Consider this unique feature of the medical profession. Although lying is snubbed in almost all other professions and trades, lying to protect a patient had somehow been considered to be justified. But in the early 1970s, medicine began to change its perspective on lying to patients. Veracity in hopeless cases is now preferred.1 Is lying ever justified in orthodontics? Despite our freedom from dealing with life-and-death issues, some situations arise in daily practice that can present a forum for lies. Consider the youngster with an overretained, mobile deciduous second molar in which the succedaneous tooth is diverted lingually by the retained molar. Your request for the dentist to extract the tooth has been ignored for the patient's last 3 visits. It's tempting to tell Junior that “I'm just looking” and snatch the tooth in a flash. Or that plea for a debanding date that is heard by orthodontists around the globe might initiate the temptation to provide a flippant, untruthful answer to silence the question. Lying in a clinical setting breeds mistrust between the patient and the orthodontist, can create psychological trauma, and shows disrespect for a person. Also, lying can be destructive to an orthodontist's reputation—and is morally wrong.2 Despite your best intentions, does your effort at preserving Eric's dental health justify the falsehood you blurted out about his hygiene? Ethics is rarely absolute; often two apparently conflicting ethical principles need to be weighed against one another: beneficence and veracity, in this case. But in retrospect, perhaps your further persistence regarding Eric's home care might have been the order of the day, even if it required more patience on your part. After all, few would contest that honesty is the best policy. REFERENCES 1. Brannigan MC, Boss JA. Moral theory. In: King K, Williams M, editors. Healthcare ethics in a diverse society. Mountain View, Calif: Mayfield; 2001. p. 145. 2. Rule J, Veatch RM. Dealing honestly with patients. In: Bywaters L, Harmon L, editors. Ethical questions in dentistry. 2nd ed. Chicago: Quintessence; 2004. p. 175.
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