Ethics: Judgment and Informed Consent

Henrik Hansen, DDS

An interesting situation came up recently. A patient of mine was experiencing pain in tooth No. 19. I referred her to an endodontist, but the prognosis wasn’t good due to extensive distal root decay. After a discussion regarding the options if she had it extracted, I sent her to an oral surgeon due to an autoimmune disease and the difficulty involved in removing the tooth. After the consultation, I spoke to the oral surgeon who asked, “What about 30?” Ah, No. 30. Well, the patient and I had discussed that particular tooth on multiple occasions. It is floating in a sea of soft tissue without any bone support, but completely asymptomatic. The patient wanted to delay extraction until it hurt. I had discussed the medical and dental risks involved, including the danger to the adjacent teeth, which at the moment had minimal pocketing. The oral surgeon also went over the dangers it presented to her health and was quite strenuous in arguing to have both teeth removed at the same time. I agreed completely that it would be the best course of action and told the patient the same. However, she was adamant in denying permission.

Since then, I have been thinking about the ethical principles involved. The ethical principal of veracity demands that we, as doctors, have a duty to fully inform our patients of the consequences of their treatment options, including no treatment. Competence means that in formulating those options, we must use our experience, training and best judgment. Beneficence and integrity mean we can’t allow a patient to dictate treatment that we know is below the standard level of care. However, this case is different, the patient is not allowing recommended treatment. We can’t perform treatment without informed consent; that could be considered the tort of battery. If we verbally push so hard that they give a reluctant OK, is this truly informed consent or coercion? And finally, there’s autonomy. As long as the patient is competent to make decisions and is fully informed, they have a right to decide what is done to their body.

In all of this is the issue of being fully informed. I think back many years ago to when a patient was considering orthodontics for herself. After the referral, the orthodontist asked if I wanted to attend the consultation with the patient, which I accepted. During the 30-minute session, the patient smiled, nodded and obviously understood nothing he said. He spoke about occlusion, maxillary protrusion and other terms that most nondental professionals would be clueless about. There was no informed consent here. I learned a valuable lesson that day. Since then, I always begin a treatment discussion with, “As I present your options, if there’s anything that isn’t clear, please stop me and I will rephrase. It’s important that you fully understand what I’m saying.” If they say, “Gee, Doc, I trust you,” I tell them that I appreciate that and it’s very flattering to hear, but humor me.

Being successful in our profession isn’t easy. It requires competence, dedication and a great amount of people skills, but the people make it worthwhile.

Henrik Hansen, DDS, is a general dentist practicing in Fairfield, Calif. He served on the CDA Judicial Council and is past chair of the Council on Peer Review and a past member of the ADA Council on Dental Benefit Programs.