DENTAL ETHICS


retainers, which are oſten required due to the inherent instability of the aligned teeth, necessitates further intervention. Even bleaching, which at first seems ultra-safe, can result in sensitivity and may necessitate replacement of restorations. Also, if you overdo it, you have many years of drinking strong coffee and smoking Gauloises to reverse the process. Proponents of these techniques might argue that virtually all


dental treatment, from bitewing radiographs to implants, are risky. Tere is no reason to distinguish cosmetic treatments. Yet, when a patient presents with, for example, a carious or fractured tooth, the advantages of intervention are usually palpable, whereas doing nothing is oſten the riskiest approach. Purely cosmetic cases are a different kettle of fish. Here, the argument runs, there is little risk in doing nothing, other than the likelihood that patients will remain dissatisfied with their smiles. All the tangible risk lies with the interventionist approaches in their various guises. Some in the profession have expressed profound reservations regarding such treatments. An oſt-cited example involves cases where dentistry is carried


out on sound teeth solely for the purpose of matching them with restorations placed to improve neighbouring teeth. In experienced, skilled hands the results can be superb. However, there is a body of opinion that regards preparing healthy teeth in order to satisfy the subjective and possibly transient concept of the “perfect smile” to be beyond ethical boundaries. Te argument is oſten captured by the so-called “daughter test”.


Would you carry out this treatment on your daughter? No? Well don’t do it on someone else’s daughter. Tis test, in many instances, provides the practitioner with a valuable yardstick. Yet, it does not offer an ethical nirvana.


perfection Patient autonomy is now a cornerstone of modern healthcare


delivery. Terefore, whether you would provide a treatment to your daughter may not be the point. What if your daughter, if competent and properly consented, wished to undergo elective cosmetic dentistry? She may be delighted, even empowered, by the resulting improvement. Surely, denying her all that modern dentistry has to offer because you regard it as morally unacceptable smacks of paternalism, the scourge of today’s medical ethics? Even if you remain unwilling to carry out the desired treatment, your daughter might reasonably expect a referral for further assessment. Failing this, she may go elsewhere.


Patient choice Tis leads us nicely to the next controversy. Most of those in primary healthcare settings tend to rely upon patient satisfaction and return business to pay the bills. General practices remain afloat by catering not only for patients’ needs but also (within limits, one hopes) their wishes. But that certainly does not mean dentistry should be patient-led. Even the most enthusiastic


SPRING 2015


patient request will not validate unsuitable or unrecognised treatment choices. However, if dentists are unable or unwilling to offer conventional, applicable cosmetic techniques, patients may vote with their feet, taking their chequebooks with them. Terefore, at some point, even the most risk-averse, conservative dentist may be tempted to undertake cosmetic procedures. Yet, the refuseniks are not necessarily troubled by the image of


a dentist reluctantly bowing to a patient’s demand for wall-to- wall veneers. Quite the contrary – the focus of their concerns is the possibility that patients may be beguiled or induced into such treatments, perhaps with the aim of maximising revenue. Te irreversibility and unpredictability of certain procedures, which look so straightforward on carefully edited TV makeover shows, might be underplayed. Te likelihood that costly replacement or even extension of the initial work will be required in the future might be lost in translation. “Before” pictures look as though the patient has been


photographed under a 40-watt bulb just aſter being told that the cat has died. In the “aſter” picture, the patient has clearly had a professional makeover and, judging by her smile, is holding the winning lottery ticket. I have little doubt that the vast majority of practitioners aim to employ impeccable consenting methods. However, patient expectations combined with financial pressures make the slope that bit more slippery. Te critical importance of patient autonomy is undeniable and


may well dictate that it should be the competent patient and not the dentist who decides whether the risks associated with elective cosmetic interventions are acceptable. Yet, this argument evaporates where the patient’s decision is based upon incomplete or inaccurate information. Lest we forget, the subjective nature of what constitutes a good aesthetic outcome already increases the chance of disappointment and conflict. Where the consenting process has strayed, perhaps inadvertently, from explanation to seduction, complaints, claims and GDC referrals may well follow. Obviously, in the course of the subsequent investigation, the


practitioner’s treatment planning and execution will come into play. However, it is the issue of consent which is oſten subject to the most forensic scrutiny. Terefore, members should, if challenged, be able to produce (in addition to excellent records) a bespoke consenting document (quite separate from the costing schedule) which must recap on the patient’s presenting complaint and the resulting discussions. It must also accurately describe the agreed procedure, its limitations and the recognised complications in layman’s terms. Visual aids which provide a realistic concept of the aesthetic outcome are most helpful. Finally, other approaches must be set out. Tis must include the most obvious yet frequently overlooked alternative - the option of doing nothing. If a consensus cannot be reached and the document remains unsigned, treatment should not proceed. Even the most giſted operator employing well-accepted


techniques will have to deal with problems such as non-vital pulps, failed restorations and disappointing aesthetic results. However, where there has been a scrupulous, pragmatic consenting process, the essential relationship of trust should remain intact.


n Doug Hamilton is a dental adviser at MDDUS 19


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