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Ethics and esthetics
E T H I C S
AT
C H A I R S I D E
Ethics and esthetics J o h n A. G ilb ert, D M D , M L A oday’s dental m arketplace is filled with new and exciting esthetic p ro ducts. C om posite resins, porcelain veneers, in lay s and o n la y s—a lo n g w ith improved porcelain crowns and ceramometal crowns—have opened new horizons for solving some of dentistry’s most difficult problems. Several tabloids are dedicated entirely to esthetic products and techniques, and almost all dental publications have m ultiple articles on esthetics. A com puter program recently developed for use on the office p erso n al com puter projects the p atien t’s teeth on the screen a n d th en alters th e ir im age u sin g “ com puter m agic” so that the p a tie n t can “preview” anticipated esthetic dental changes. T h e advent of this “ esthetic re v o lu tio n ” raises m any ethical questions. Are dentists creating a “need” for services that were not a problem for the patient u n til an analysis occurred? S h o u ld in su ran c e pay for such services? Given the large unm et need for dental care in the U n ite d States, sh o u ld d e n ta l resources be dedicated to largely “cosmetic” services? Do o u r patien ts fully un d erstan d the im p lic a tio n s of esth etic treatm en t? A discussion of these issues best follow s the o u tlin e p ro p o sed in a p rev io u s a rtic le 1: beneficence/nonmaleficence, and justice.
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Nonmaleficence A caring dentist wants to do good (beneficence). He or she sees defects in a p a tie n t’s sm ile that he or she thinks are unesthetic. These problems are carefully diagnosed and analyzed. A treatm ent p lan that involves altering the shape an d co lo r of the a n te rio r teeth is presented to the patient. T he patient has the right to refuse or accept the treatment plan. T he dentist has fulfilled his or her ethical obligation—correct? It is from the H ip p o cratic o ath th at the p rin cip le of nonm aleficence takes its root. T his principle has been widely accepted by h ealth care providers th ro u g h the ages. It states that, above all, the physician (or dentist), m ust do no harm . If the p atien t had come to the dental office seeking advice about an un attractiv e sm ile, then this p rin c ip le has not been violated. However, if patients, up to th is tim e, h ad no concern a b o u t the appearance of their smiles (in fact, they may believe they have good smiles w ith attractive teeth), and it is the dentist w ho introduces problem s, the p rin cip le of nonm aleficence may well have been violated. Brisman2 points out that there are clear differences between 490 ■ JADA, Vol. 117, September 1988
what is esthetic to dentists and what is esthetic to the gen eral p u b lic .-H a s the d en tist, in this situation, created a problem where none existed? In the extreme, it could be argued that the dentist has the potential, via esthetic analysis, of doing great harm . An entire personality ch an g e co uld take place in a p erso n w ho received information from a professional expert (the d en tist) th a t a sm ile is n o t “ u p to stan d ard .” Even in more routine cases, the planting of a “seed of doubt” when relating esthetic in fo rm atio n to a p a tie n t can have serious short- and long-term consequences. Autonomy The patient’s autonomy must also be respected w hen esth etic services are p ro p o sed . T h e dentist’s desire to do good should not overrule the p a tie n t’s rig h t to make clear, inform ed decisions. T he patient must be informed that com posite resin m aterials req u ire p erio d ic re p a ir or rep lacem en t, an d th a t there is in su ffic ie n t d ata c o n cern in g the life sp an of porcelain veneers and inlays and onlays. Porcelain does fracture and can cause excessive wear on opposing dentition. The patient must also understand that tooth structure w ill be removed (in most cases), and this will commit the patient to lifelong treatment of involved teeth. Periodontal considerations should also be ex p lain ed an d discussed. T hese factors should be presented on an equal plane with the benefits of q u a lity esthetic services so th at the p a tie n t can m ake an auto n o m o u s decision. T he patient’s desire not to have an esthetic analysis must also be respected. T h e routine inclusion of a detailed esthetic diagnosis and treatm en t p la n in every den tal e v alu a tio n cannot be justified. Only if the patient gives clear indication th at he or she has esthetic concerns should such an analysis be provided. Justice T he justice issues related to esthetic care are complex. There are individuals whose appear
ance represents a handicap. T h e correction of these problem s, given all the social and p sy ch o lo g ical benefits of su ch treatm en t, clearly is a good investm ent, either by the individual, society, or other third-party payers. In many cases, the patient will show interest in m aintaining health only if esthetic concerns are also addressed. But when is the ethical line crossed? When do esthetic corrections become strictly cos metic? In addition, when should the individual be required to pay for such services with no assistance from insurance or society? We have all seen the patient with beautiful teeth who w ants veneers (usually because some friend or fam ily m em ber once said, “ Y our teeth look yellow.”) Does this patient have a problem or not? T he answer is not clear-cut and can probably be made only on an individual basis (som etim es o n ly w ith the assistance of a psychiatric or m edical co n su ltatio n ). Most th ird -p a rty carriers offer n o (or reduced) benefits for “cosmetic” care. T his approach may unfairly penalize individuals for whom such care is of primary importance. Even m ore com plex th a n the in d iv id u al ju stice issues are those th a t deal w ith the d is trib u tio n an d u tiliz a tio n of m anpow er and services in our dental health care delivery system. S hould these resources be spent on porcelain veneers for individuals w ith m ild tetracycline staining, or on the m illions of Americans with limited access to dental care and a huge unm et need for basic treatment? Today’s practicing dentist should examine his or her motives in providing esthetic dental treatment and should make his or her decision only after a thorough exploration of the ethical issues involved in delivering such care.
---------------- JA D A ---------------Send contributions to T h e J o u rn a l o f th e A m erican D e n ta l A s s o c ia tio n , A D A , 211 E C h ic a g o A ve, Chicago, 60611. 1. Gilbert, J.A. Posterior com posites: an ethical issue. Oper Dent 12(2):79-81, 1987. 2. B rism an , A .S. E sthetics: a c o m p a r iso n of d entists’ and patien ts’ concepts. JADA 100(3):345352, 1980.
E th ic s at C h a irsid e is a regular feature o f T h e J o u r n a l that focuses o n eth ical and profession al issu es in the practice o f dentistry. It is edited by D avid T . Ozar, P h D , o f L oyola U n iversity o f C h ic a g o ’s D e p a r tm e n t o f P h ilo s o p h y a n d S c h o o l o f D e n tis tr y , in a s s o c ia t io n w ith th e sta ff o f T h e J o u r n a l an d w ith th e a s sis ta n c e o f m em b ers o f th e P r o fe s sio n a l E th ic s in D e n tis tr y N e tw o r k (P E D N E T ). T h e v ie w s e x p r e sse d in th is s e c tio n are th e v ie w s o f the authors and are n ot in ten d ed to represent the view s of the A m erican D en tal A ssociation , P E D N E T , or the editors. Dr. G ilb ert is an associate professor, S ch ool o f D entistry, U n iversity o f M issouri-K ansas City.
AT
C H A I R S I D E
Ethics and esthetics J o h n A. G ilb ert, D M D , M L A oday’s dental m arketplace is filled with new and exciting esthetic p ro ducts. C om posite resins, porcelain veneers, in lay s and o n la y s—a lo n g w ith improved porcelain crowns and ceramometal crowns—have opened new horizons for solving some of dentistry’s most difficult problems. Several tabloids are dedicated entirely to esthetic products and techniques, and almost all dental publications have m ultiple articles on esthetics. A com puter program recently developed for use on the office p erso n al com puter projects the p atien t’s teeth on the screen a n d th en alters th e ir im age u sin g “ com puter m agic” so that the p a tie n t can “preview” anticipated esthetic dental changes. T h e advent of this “ esthetic re v o lu tio n ” raises m any ethical questions. Are dentists creating a “need” for services that were not a problem for the patient u n til an analysis occurred? S h o u ld in su ran c e pay for such services? Given the large unm et need for dental care in the U n ite d States, sh o u ld d e n ta l resources be dedicated to largely “cosmetic” services? Do o u r patien ts fully un d erstan d the im p lic a tio n s of esth etic treatm en t? A discussion of these issues best follow s the o u tlin e p ro p o sed in a p rev io u s a rtic le 1: beneficence/nonmaleficence, and justice.
T
Nonmaleficence A caring dentist wants to do good (beneficence). He or she sees defects in a p a tie n t’s sm ile that he or she thinks are unesthetic. These problems are carefully diagnosed and analyzed. A treatm ent p lan that involves altering the shape an d co lo r of the a n te rio r teeth is presented to the patient. T he patient has the right to refuse or accept the treatment plan. T he dentist has fulfilled his or her ethical obligation—correct? It is from the H ip p o cratic o ath th at the p rin cip le of nonm aleficence takes its root. T his principle has been widely accepted by h ealth care providers th ro u g h the ages. It states that, above all, the physician (or dentist), m ust do no harm . If the p atien t had come to the dental office seeking advice about an un attractiv e sm ile, then this p rin c ip le has not been violated. However, if patients, up to th is tim e, h ad no concern a b o u t the appearance of their smiles (in fact, they may believe they have good smiles w ith attractive teeth), and it is the dentist w ho introduces problem s, the p rin cip le of nonm aleficence may well have been violated. Brisman2 points out that there are clear differences between 490 ■ JADA, Vol. 117, September 1988
what is esthetic to dentists and what is esthetic to the gen eral p u b lic .-H a s the d en tist, in this situation, created a problem where none existed? In the extreme, it could be argued that the dentist has the potential, via esthetic analysis, of doing great harm . An entire personality ch an g e co uld take place in a p erso n w ho received information from a professional expert (the d en tist) th a t a sm ile is n o t “ u p to stan d ard .” Even in more routine cases, the planting of a “seed of doubt” when relating esthetic in fo rm atio n to a p a tie n t can have serious short- and long-term consequences. Autonomy The patient’s autonomy must also be respected w hen esth etic services are p ro p o sed . T h e dentist’s desire to do good should not overrule the p a tie n t’s rig h t to make clear, inform ed decisions. T he patient must be informed that com posite resin m aterials req u ire p erio d ic re p a ir or rep lacem en t, an d th a t there is in su ffic ie n t d ata c o n cern in g the life sp an of porcelain veneers and inlays and onlays. Porcelain does fracture and can cause excessive wear on opposing dentition. The patient must also understand that tooth structure w ill be removed (in most cases), and this will commit the patient to lifelong treatment of involved teeth. Periodontal considerations should also be ex p lain ed an d discussed. T hese factors should be presented on an equal plane with the benefits of q u a lity esthetic services so th at the p a tie n t can m ake an auto n o m o u s decision. T he patient’s desire not to have an esthetic analysis must also be respected. T h e routine inclusion of a detailed esthetic diagnosis and treatm en t p la n in every den tal e v alu a tio n cannot be justified. Only if the patient gives clear indication th at he or she has esthetic concerns should such an analysis be provided. Justice T he justice issues related to esthetic care are complex. There are individuals whose appear
ance represents a handicap. T h e correction of these problem s, given all the social and p sy ch o lo g ical benefits of su ch treatm en t, clearly is a good investm ent, either by the individual, society, or other third-party payers. In many cases, the patient will show interest in m aintaining health only if esthetic concerns are also addressed. But when is the ethical line crossed? When do esthetic corrections become strictly cos metic? In addition, when should the individual be required to pay for such services with no assistance from insurance or society? We have all seen the patient with beautiful teeth who w ants veneers (usually because some friend or fam ily m em ber once said, “ Y our teeth look yellow.”) Does this patient have a problem or not? T he answer is not clear-cut and can probably be made only on an individual basis (som etim es o n ly w ith the assistance of a psychiatric or m edical co n su ltatio n ). Most th ird -p a rty carriers offer n o (or reduced) benefits for “cosmetic” care. T his approach may unfairly penalize individuals for whom such care is of primary importance. Even m ore com plex th a n the in d iv id u al ju stice issues are those th a t deal w ith the d is trib u tio n an d u tiliz a tio n of m anpow er and services in our dental health care delivery system. S hould these resources be spent on porcelain veneers for individuals w ith m ild tetracycline staining, or on the m illions of Americans with limited access to dental care and a huge unm et need for basic treatment? Today’s practicing dentist should examine his or her motives in providing esthetic dental treatment and should make his or her decision only after a thorough exploration of the ethical issues involved in delivering such care.
---------------- JA D A ---------------Send contributions to T h e J o u rn a l o f th e A m erican D e n ta l A s s o c ia tio n , A D A , 211 E C h ic a g o A ve, Chicago, 60611. 1. Gilbert, J.A. Posterior com posites: an ethical issue. Oper Dent 12(2):79-81, 1987. 2. B rism an , A .S. E sthetics: a c o m p a r iso n of d entists’ and patien ts’ concepts. JADA 100(3):345352, 1980.
E th ic s at C h a irsid e is a regular feature o f T h e J o u r n a l that focuses o n eth ical and profession al issu es in the practice o f dentistry. It is edited by D avid T . Ozar, P h D , o f L oyola U n iversity o f C h ic a g o ’s D e p a r tm e n t o f P h ilo s o p h y a n d S c h o o l o f D e n tis tr y , in a s s o c ia t io n w ith th e sta ff o f T h e J o u r n a l an d w ith th e a s sis ta n c e o f m em b ers o f th e P r o fe s sio n a l E th ic s in D e n tis tr y N e tw o r k (P E D N E T ). T h e v ie w s e x p r e sse d in th is s e c tio n are th e v ie w s o f the authors and are n ot in ten d ed to represent the view s of the A m erican D en tal A ssociation , P E D N E T , or the editors. Dr. G ilb ert is an associate professor, S ch ool o f D entistry, U n iversity o f M issouri-K ansas City.