Most dentists involved with Spear dedicate significant time, money and resources – not to mention sacrificing days out of the office and away from the family – to learn how to stay on the cutting edge of modern dentistry so that we can provide our patients with the most current and appropriate care for their needs.
We acknowledge that while there is only one appropriate diagnosis for a given case, there are many treatment plan possibilities. In a perfect world, our patients would only accept this:
The ethically driven and evidence-based appropriate treatment that their dentist presents, which must be based on a co-diagnostic process in which their esthetic desires and functional needs are addressed and that are supported with adequate and stable tooth and bone structure in a biologically healthy environment.
These are the tenets of what we know as the Spear Facially Generated Treatment Plan process, and they set the stage for predictability in the care that we provide.
Unfortunately, there are some patients who have a mindset about their care that simply is not congruent with this philosophy of practice. When they present, we need to make decisions about whether to accept them as a patient. That decision should be based on what we think of their capacity to learn about appropriate care choices or other limitations, such as those posed by financial need, financial choices or third party involvement (spouse, significant other, parent or insurance company). In such situations, a formal ethical decision-making method can be helpful in deciding who to treat and under what conditions.
The Challenging Dental Patient
As an example, earlier this year a gentleman in his mid-50s rode his brand new Harley-Davidson Ultra Classic motorcycle (top of the line, for those non-bikers who might be reading this) into my parking lot for an emergency appointment. While in no way do I advocate for “diagnosing the pocketbook,” in my experience what a patient drives, how they dress and how they act tend to be hints about their value system. However, these perceptions are often incorrect. So, we try not to assume anything. Besides, even though a person values the toys he has or the clothes he wears, it often has no bearing on their concept of oral health.
This particular patient had a fractured maxillary right second molar. The tooth was not painful to percussion and had no periapical pathology, but it had over 50 percent bone loss with a 7 mm periodontal pocket on the distal, and it had no opposing tooth. The lingual cusps had fractured horizontally well above the gingiva. The patient requested extraction, even though we discussed options for restoration and periodontal therapy in an attempt to save the tooth. Based on this discussion, the patient opted for extraction of that particular tooth. Given that extraction was, in my opinion, an appropriate option, I believe that the tenets of informed consent were met, and the tooth was extracted without incident.
I then recommended that the patient return for a comprehensive evaluation to assess further needs, which he did. During his co-discovery appointment, he expressed that he did not want to spend any significant money on this teeth but wanted to take care of any pressing active disease (active caries and periodontal disease). However, he did not schedule any treatment despite two attempts to reach him by phone follow-up. This was a red flag that this patient may tend to be non-compliant.
Seven months later, the patient presented again to my office, this time with the chief complaint of a broken cusp off his right first molar, for which I had previously recommended a crown.
The conversation went like this:
Patient: “My tooth broke, and I want it either pulled or filled, whichever is cheapest.”
Doctor: (after examining the tooth): “This is the tooth that we previously talked about needing something like a crown, and it looks like it has broken further like I had predicted. It appears to be an otherwise healthy tooth with no significant bone loss or gum problems, and the pulpal health seems to be good. It’s just in need of repair. Therefore, I don’t believe that pulling the tooth is in your best interest, so we should talk about other options to fix the tooth. If we don’t fix it, the tooth probably will not become painful for some time as long as you keep it clean, but it will likely continue to break off in pieces, and ultimately you might lose the tooth, but you might not.”
Patient: “What’s the cheapest option?”
Doctor: “That’s not an easy question. In my opinion, the best, and I think the least costly in the long run in terms of frustration, pain and dependability, is a crown, which costs approximately $1,400. There are some other options that I would not recommend because they are likely to fail under the stresses that you put on them, like a large tooth colored filling or large ‘silver’ filling with pins. In my opinion, you will not be satisfied with either of those options because you’ve already told me that you don’t want work that will need to be redone in a few years, which is more likely with a filling than with a crown. Besides, you have proven that a large filling will not hold up under your chewing forces. However, I will not pull the tooth because it would be better for you to simply not treat the tooth at this time than to extract an otherwise healthy tooth.”
Patient: “That’s not your decision, Doc! I just want the tooth pulled, and that’s all there is to it.”
Pull Out the B-A-N-J-O
At this point, it should be obvious that I was stuck in the middle of an ethical quandary. How do I treat the patient in his best interest, avoid doing harm to him, treat him in a fair way that doesn’t leave him wandering without a dental home, and honor the ethical principle of autonomy? There is only one way: to work through an ethical decision-making process quickly and efficiently through the use of an acronym that I have coined over the years. It was time to play the B-A-N-J-O!
Benevolence. It is our duty to do well for the patient, and hopefully help them in the process. In the example of my patient, it was better to leave the tooth untreated in its existing condition rather than to extract it because of its healthy, functional nature, despite the indication for coronal repair.
Autonomy. Autonomy is the ethical principle that says both the patient and the dentist have autonomy. The patient, when he has a reasonable understanding of his options, can choose his course of care and even who treats him. It is often overlooked that dentists also have autonomy to choose what kind of care they want to provide and to whom. Of course, many factors may infringe on rights of autonomy like third-party payers, for example. In the example I’ve presented above, my patient had the right to say no to all of the treatment that I offered to him, and he had the right to request extraction. However, I had the right to choose not to perform what I determined to be inappropriate treatment.
Non-maleficence. It is our duty as clinicians to do no intentional harm to the patient. Of course, sometimes pain cannot be avoided in providing care, but it is our duty to take necessary reasonable steps for patient comfort. We also have a duty not to provide care that we reasonably believe with do harm to a patient. For example, pulling a relatively healthy tooth simply because the patient chose not to want to pay for appropriate treatment, in my opinion, would have breached this duty.
Justice. Dentists have a duty to treat our patients fairly and in accordance with reasonable standards of care. In other words, what treatment options would we offer to several patients in the same situation? Since money was of primary concern to this patient – not the lack thereof, but the unwillingness to assume financial responsibility for his own healthcare – it was my obligation to offer him the same options I would give another person who was hindered from care due to financial concerns, which I did. I offered the opportunity for him to contact the program administered by our state in collaboration with our state dental society to assist those who are in financial difficulty and who do not qualify for dental insurance of any kind; a referral to our local safety net clinic; and a referral to our local dental graduate residency program.
Oh, gosh! I have to tell the truth: I’ve used poetic license here to substitute “O” for “V,” which stands for veracity. It is a dentist’s ethical duty to be truthful with our patients, even when we are certain that the reception will be cold. Often a sense of morality comes into play here rather than just ethics – morality is the little voice inside your head that says, “It’s just not right for me to …” For example, telling a patient that while a certain restoration is possible, it is not the appropriate restoration in their situation for a specific reason. In my clinical example, a large amalgam restoration was, in my opinion, not the most appropriate restoration for him because I have never been gifted in building amalgam crowns, and the contours as well as function of the restoration would have likely been compromised. I also had to truthfully tell the patient that his general attitude was not conducive to me treating him according to my standards of care.
When you play the B-A-N-J-O correctly, all the strings strum together to create a beautiful melody. I have found that in tough ethical situations, breaking the problem down one by one by the ethical tenets set out by the ADA Code of Ethics and Professional Conduct helps me come to a relatively quick resolve.
In this particular case, I rescheduled the patient to discuss treatment further the next day because I wanted to think about it overnight. Ultimately, I invited this particular patient to leave my practice to find another practice that would better match his personal philosophy. He told me that he didn’t want to pursue any of the options that I suggested because he was “… too proud to take advantage of anyone.” I provided him a copy of his records and wished him well.
1. K. Huff, C. Farah, M. Huff. Ethical Decision Making for Multiple Prescription Dentistry. General Dentistry. September/October, 2008. 538-547.
3. K. Huff, W. Leffler, D. Cambell. Ethics are Moral, but Morality is not Ethics. General Dentistry. September/October, 2008. 504-505.
(Click this link to read more dentistry articles by Dr. Kevin Huff.)
Kevin D. Huff, D.D.S., Spear Moderator and Contributing Author - www.doctorhuff.net