ETHICS IN ORTHODONTICS

When to say “I’m sorry”

Peter M. GrecoPhiladelphia, Pa

It’s been another long day at the office, and it’s aboutto get longer. As you sit down at your desk after dis-charging your last patient of the day, you review the

diagnostic records produced for 12-year-old Susan. Youcompleted early intervention for her a few years ago toclose the diastemata between her maxillary incisors,per her parent’s request, and today’s progress filmsshow over 50% root resorption of the maxillary lateralincisors. Your heart rate accelerates as you fumblethrough her chart for the original films. The films indi-cate that the contact between the lateral incisor apicesand the crowns of the permanent canines might havecontributed to the severe resorption. You reluctantlyconclude that it was probably your treatment that ledto the root loss.

Your treatment planning conference with the par-ents, who are prominent physicians, is scheduled in 1week. Should you inform the family of the potentiallyiatrogenically-induced findings? If you suspect thatthe root resorption was caused by your treatment, wouldyou consider apologizing to the family?

Many legal and ethical experts would concur that dis-closure—informing the family of an unexpected treat-ment outcome—is an essential component of the ethicalprinciple of veracity (truth-telling). But an apology is of-ten ill-advised by malpractice insurance carriers. Yet, theissue deserves some attention from an ethical perspec-tive—a perspective that has some strategic benefits.

A number of renowned academicians have perceivedgreat merit in offering an apology when a patient hasbeen harmed by treatment. Dr Lucian L. Leape1 of Har-vard’s Medical School asserted that many lawsuits wouldinvolve significantly smaller settlements or might beeliminated altogether if the caregiver offered a sincereapology in cases of unfavorable outcome. He explainedthat patients expect someone to take responsibility forthe occurrence and want to feel that future patientswill be spared the same results. According to Dr Leape,an apology heals both parties in several ways, not theleast of which are the following:

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1. It restores a patient’s self-respect by diminishing thehumiliation commonlyperceivedby an injuredpatient.

2. It reaffirms the trust between provider and patient.3. It assures the patient that he or she is not at fault for

what happened.4. It provides confirmation for the patient that he or

she is safe in the provider’s hands.

Professor Charles Vincent2 observed that injuries thatare a consequence of therapy differ from other injuries.He stated that an injury from treatment is especially trau-matic because patients are harmed by those whom theyhave trusted to help them and often continue to seekcare from those same providers. Such factors invoke feel-ings of “fear, loss of trust, and isolation” in the patient.Vincent cited the consequences to the provider, includinga complex sense of embarrassment, ego violation, confi-dence, and, most importantly, fear of legal retribution.Yet, he values an apology as a viable solution for all in-volved.

Psychological remuneration for the provider is an-other product of an apology. Beverly Engel,3 an authorwho has studied apologies and their benefits, stated,“While an apology cannot undo harmful past actions,if done sincerely and effectively, it can undo the negativeeffects of those actions.”

Will an apology increase a provider’s vulnerability ina malpractice suit? Law professors Sciatta and Hodge4 as-serted that “apologies by physicians result in a decrease inthe monetary losses that would result from litigatinga malpractice claim.” They cited studies from many statesin which apologies resulted in more timely settlementsand decreased financial remuneration for the injuredparty. For example, several hospitals in Virginia thathave enacted “I’m sorry” policies have seen settlementsin medical malpractice cases reduced dramatically. “I’msorry” policies involve investigation of untoward occur-rences, offers of financial retribution, and apologieswhen appropriate. Thirty-four states and the District ofColumbia have legislated apology laws that exclude anapology as admissible evidence during malpractice trialsin an effort to encourage physician apologies.

How do you handle your problem of the severe rootresorption in young Susan? Disclosure is imperative.Prompt discussion with your malpractice carrier is

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certainly indicated. From this practitioner’s perspective,an apology and remediation might certainly be viableoptions when communicating with her parents.

The author is grateful to Dr James T. Rule for his re-view of this article.

American Journal of Orthodontics and Dentofacial Orthoped

REFERENCES

1. Leape LL. Understanding the power of apology: how saying I’msorry helps heal patients and caregivers. Natl Patient Safety Founda-tion Newsletter 2005;8:1. Available at: http://www.npsf.org/download/Focus2005Vol8No4.pdf. Accessed on October 2, 2011.

2. Vincent C. Understanding ane responding to adverse events. N EnglJ Med 2003;348:1051-6.

3. Engle B. The power of apology. Psychol Today 2002. Available at:http://www.psychologytoday.com/articles/200208/the-power-apology. Accessed on October 3, 2011.

4. Sciatta NM, Hodge SD. To apologize for an unforeseen medicalcomplication—a primer on apologies laws. Penn Bar Assn Q 2011:July, 93-110.

ics June 2012 � Vol 141 � Issue 6