The pursuit of perfection

PRIMUM non nocere” – first do no harm. The Hippocratic oath can be said to apply to dentists as much as doctors. But how does this relate to a world where we surgically change the size and shape of our bodies, decorate our skin with tattoos and piercings and seek the “perfect” smile? And what is the balance between patient autonomy and professional paternalism?

The increase in private dentistry and patient expectations has created new ethical dilemmas. Society has moved from basic dental treatment to advanced restorative treatments. Many of these destroy tooth tissue. Cosmetic dentistry can be defined as a procedure carried out in the absence of dental disease or pathology. Is a patient entitled to have sound tooth tissue removed solely for the purpose of improving the look of their teeth? How should a dentist deal with this ethical quandary?

One way is the ‘daughter’ or ‘partner test’ which has existed for many decades. In effect it is the ultimate ethical test of any dental treatment: would you carry out this treatment on the person for whom you care the most?

Patient autonomy

Judge Cardozo stated in 1914 in the case of Schloendorff v Society of New York Hospital: “Every being of adult years and sound mind has a right to determine what shall be done with his own body.” However, the rise in patient power poses the ethical question of where the border lies between patient autonomy and dental paternalism or ‘dentist knows best’? Ethically patients have the right to make bad decisions. But the final judgement is with you, the clinician. If you do not feel ethically comfortable with a line of treatment you should not carry it out.

The patient may, when older, regret a treatment that shortens the life of a tooth. But also it could be argued that the short-term benefit of a treatment may outweigh the longer term downside. Life-changing personal or professional events can be attributed to improved aesthetics and improved confidence. Who are we to take away the patient’s right of autonomy?

Informed consent and record keeping

As with much ethics, there is no right or wrong in this issue. The decision may rest with the patient in assessing the degree of personal benefit and dental loss expected by the procedure. But it is essential that the dentist discusses this decision as part of informed consent. Most importantly, this process should be DOCUMENTED. If a procedure goes wrong or does not meet patient expectations the first accusation will probably relate to the patient denying that informed consent was obtained. It is then that you and your defence organisation will have to prove that it was. What should you do? First, contact your defence organisation, second, contact your defence organisation, third… Never ever reply to a complaint or accusation about the quality or necessity of your treatment without consulting your defence organisation.

The lack of clinical necessity for a procedure makes the consent process the key event. Research shows that it is actually quite rare for patients to remember all that they were told. In his 2006 study, ‘Informed Consent – a contemporary myth?’, Professor R Lemaire wrote: “A number of studies have shown that retention of medical information is at best fragmentary, and that it is selective and decreases over time”.

Your records are key to demonstrating this. You have 2,000 patients; the patient has one dentist. If it comes to a judge deciding whose recall of events is better they may well take the patient’s opinion. However, good clinical records explaining what was offered and why, detailing options, alternatives (including doing nothing), success rate, costs, benefits, risks, side-effects, complications, aims, rationale, what is involved, likely consequences, limitations, risks and advantages for all possibilities will provide a sound defence. The more complex and expensive the treatment you provide the more you should write in your records.

GDC guidance

In its guidance Principles of patient consent, the GDC advises that you should always provide a written treatment plan and cost estimate. The patient should be given sufficient information, the consent should be voluntary and the patient should have the ability to understand the information given. Profit and personal gain should not be seen as the primary driver of a treatment plan. Putting patient interest first is the GDC’s primary principle.

It is important also to allow the patient time to consider the large amount of information you have given them. Use balanced written information and not advertising matter produced by a manufacturer. Try not to speak with abbreviations and technical language. Never pressurise the patient into a line of treatment – even if they ask “what would you do doctor?”

Finally, the more you show you care for your patients the more your patients will believe in you.

Dick Birkin is Secretary of the Dental Law and Ethics Forum and acts as an expert witness to the GDC on regulations and record keeping