QUIZ

successful is positive framing. Consider the scenario shown in Table 1, based on an actual event involving two dentists in the same practice. In this case, the patient presents with irreversible pulpitis. With Dentist A, the patient opts for an extraction (option A), rather than root canal treatment (RCT) (Option B) and waits in the waiting room to have the tooth extracted. The patient’s usual dentist (Dentist B) becomes aware that his patient is in attendance and booked in with a colleague for an emergency appointment. He offers to see the patient to remove the tooth. Before undertaking the extraction, Dentist B discusses the options but frames the risk of failure differently. While Dentist A had explained that one in ten cases fail, Dentist B says nine out of ten cases are successful. The patient reconsiders the position and opts for option B. The clinical record written by both clinicians is almost identical, but there is no reference to framing. (The framing scenario only came to light because the patient commented that he felt Dentist A was being overly pessimistic and questioned the dentist’s motivation, suggesting the dentist was trying to “sell me an implant”.) Loss aversion makes a patient less likely to choose something when it is presented in terms of harm rather than benefit. It can be argued that framing is potentially manipulative when it comes to making choices.

Table 1: Framing endodontic risks.

EXAMPLE

Option A n c/o ++ pain UR Q n Kept awake three days n Caries UR6 – irreversible pulpitis n Discuss options RCT vs XLA n Discuss prognosis n Patient opts to have extraction n UR6 extracted Option B n c/o ++ pain UR Q n Kept awake three days n Caries UR6 – irreversible pulpitis n Discuss options RCT vs XLA n Discuss prognosis n Patient opts to have RCT n UR6 pulp extirpated

The principle of nudge

Richard Thaler and Cass Sunstein define a nudge as “any aspect of the choice architecture that alters people's behaviour in a predictable way without forbidding any options or significantly changing their economic incentives”.2 When we take nudge and framing together, we must consider consent. Dentists will usually have an opinion about what is in the patient’s best interests and thus may frame information in a way that nudges patients into making choices that are considered likely to maximise their welfare.3 However, while we can use the principle of nudge to encourage patients to make the right choices, it can also be used to maximise self-interest (as was alleged in the endodontic example cited). It has been argued that nudging is inconsistent with autonomy and the principle of informed consent.

Case example: the omission of truth

Dental Protection handled a case some years ago where a patient had a lower third molar extracted and she was left with a numb lip. When she failed to get a response or explanation from the dental practice, she contacted a solicitor for advice. Copies of the clinical records were requested from the practice. On examination of the clinical record, it was clear that the patient’s recollection of events was completely different from what was written on the clinical record. It turns out that the patient could prove that one of the dentist’s claims was falsified: the patient had retained her tooth and a forensic analysis confirmed that it was her tooth. It had been extracted as a whole, contrary to the dentist’s notes, which stated that the tooth was “extracted in bits”. The dentist was removed from the register, not because of the injury, but because the records had been falsified. Ultimately, the spoken word might easily be forgotten, but written documents can always be relied on for conclusive proof. There is an old Latin proverb: ‘Verba volant, scripta manent’; which translated means ‘Spoken words fly away, written words remain’. It is true of the clinical record. Less true is the proverb ‘Dictum factum’ – ‘What is said is done’. And what is not said is perhaps more relevant.

This article is based on the lecture ‘The ethics of omission’ given by Dr Raj Rattan at the Ethics for All conference in South Africa in October 2022.

References

1. Dungarwalla, M., Bailey, E. Dentistry and aviation engineering – behind the scenes at operations in a UK-based airline. Br Den J 2021; 230: 835-840. 2. Thaler, R.H., Sunstein, C.R. Nudge: Improving Decisions about Health, Wealth, and

Happiness. New Haven: Yale University Press, 2008. 3. Aggarwal, A., Davies, J., Sullivan, R. “Nudge” in clinical consultation – an acceptable form of medical paternalism? BMC Med Ethics 2014; 15: 31.

Submitted by Dr Maura Cuffe.

Six-year-old Chloe attends with her mother Sinéad for a check-up. Chloe has additional needs and Sinead mentions that Chloe is PEG fed.

1. What is a PEG? 2. What issues should you consider? 3. Sinéad helps Chloe with toothbrushing. Chloe clamps on the brush most of the time. Any suggestions for Sinead? 4. Going forward, what are your priorities for Chloe?

Answers on page 331.