ETHICS IN ORTHODONTICS

Do the right thing.

Peter M. GrecoPhiladelphia, Pa

Your abbreviated orthodontic therapy for Ms Bellis about to conclude. The referring dentist re-quested that you upright the mandibular left

second molar a few more degrees before implant re-placement of the absent first molar. The gable bendsyou placed at last month's appointment inducedocclusal trauma with the maxillary arch, so you beginto reduce the relatively new ceramic crown on the man-dibular second molar. Suddenly, you notice that you'veperforated the second molar crown. Ms Bell has noidea of the problem as she continues to listen to themusic from her iPod. You wish you had mentioned thispossibility before your adjustment, but in your haste tostay on schedule, you hadn't.

Now your conscience kicks in. You wonder whetheryou should tell Ms Bell about the perforation. On onehand, she doesn't know it occurred, but on the other,how would you feel if future leakage caused decay tothe tooth? This would necessitate further treatment or,worse yet, potential extraction.

One of the most important ethical principles we faceeach day is that of reparation. Much of what we do forpatients occurs in the restriction of the oral cavity—a re-gion where patients know little of our failures unlessthey feel pain or perceive dysfunction. When we injurea patient, even without the patient's knowledge, ourethical duty is to provide reparation. Defined in the eth-ical sense, reparation is the duty to make amends for in-jury or damage we have caused.1

The philosopher W. D. Ross (1877-1971) proposedhis concept of “prima facie” duties, which are ethical ob-ligations indicated at “first glance”: those duties that weare bound to provide unless they are overridden by otherethical responsibilities.2 A prima facie duty carriesa strong indication for completing the obvious ethicalrequirement. Reparation is a common-sense action, un-less providing it is contradicted by another prima facieethical principle. Consider a possible scenario in ortho-dontic practice: you discover that your failure to recovera gingivally displaced separator creates a significant

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periodontal abscess. Your patient is in pain, with re-gional lymph node adenopathy and low-grade fever.Your contemplated reparation would be to retrieve theseparator as a prima facie duty. However, if your patientrequires antibiotic prophylaxis before initiating a proce-dure that induces gingival bleeding, you might delay en-tering the area in respect of the ethical principle ofnonmaleficence (do no harm). You would postpone re-trieval of the separator until the patient is adequatelypremedicated.

One advantage we have as orthodontists is that rep-aration can often be readily provided. Given the numberof patients we see each day and the high level of delega-tion inherent in an orthodontic practice, errors can anddo occur. Despite such delegation, we are responsiblefor not only our own but also our staff's actions incare delivery. If clinical misadventures do occur, it isincumbent upon us to provide reparation before it issolicited by the patient. The patient must be promptlyand accurately informed of the misadventure. Remedia-tion of the problem should be arranged without expenseto the patient. Although the purpose of professionalliability insurance is to provide the patient financialreparation in the event of a therapeutic misadventure,a patient's trust in us can be lost forever if we are notvoluntarily forthright when reparation is indicated.

In the case of Ms Bell's perforated crown, you shouldexplain the complication and offer to arrange for re-placement of the restoration. The cost of the restorationis your responsibility.

Remember, always do the right thing—even when noone is looking.

REFERENCES

1. Rule J, Veatch RM. Ethical questions in dentistry. In: Bywaters L,Harmon L, editors. Ethical principles. 2nd ed. Chicago: Quintes-sence; 2004. p. 71.

2. Garret J. A simple and usable (although incomplete) ethical theorybased on the ethics of W. D. Ross. Available at: http://www.wku.edu/�jan.garrett/ethics/rossethc.htm. Accessed on August 4, 2012.

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