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“Thou shalt not speak ill . . .”
ETHICS IN ORTHODONTICS
“Thou shalt not speak ill . . .” Peter M. Greco Philadelphia, Pa
I
t’s another second-opinion evaluation of a patient who was initially examined by the busiest orthodontist in town. Ten-year-old James comes with his mother upon referral from his neighbor. The recommendation of the initial orthodontist was that treatment was not yet indicated, but James’s mother was certain that the orthodontist’s evaluation was so hurried that it was incomplete. When she called to make the appointment, she said, “Dr Jones’s office was like a factory.” Your clinical examination reveals a midtransitional dentition with immobility of all deciduous molars and canines. Although the left first permanent molar is fully erupted, you notice that the contralateral permanent molar is infraoccluded. A panoramic radiograph confirms ectopy of the maxillary right first permanent molar. After you explain the problem, the mother pointedly asks, “Why did the other orthodontist tell me that James needed no treatment?” A moment that seems like an eternity follows. During Ronald Reagan’s 1966 race for governor of California, Republican Party chairman Gaylord B. Parkinson said, “Thou shalt not speak ill of any fellow Republican.”1 The adage was intended to prevent fragmentation of the Republican Party that might damage its profile in the election. Such loyalty to colleagues in politics is rare. The fraternal relationship between professional colleagues transcends age and geography. Loyalty to educational institutions and among classmates forms a bond that alumni organizations nurture and perpetuate. Ethically speaking, the principle of fidelity represents an act of loyalty, since it supports the keeping of promises. The question of fidelity or loyalty becomes amplified when an orthodontist is confronted by a demand for judgment of another practitioner’s recommendations or treatment results. Although treatment philosophies can differ, frank criticism of a colleague is unethical and reflects poorly on all involved persons. Negativism therefore should be avoided. Comments in a second-opinion evaluation should be confined to the here and now, and not what should have, could have, and would have been done. Dr Laurance Jerrold’s suggested response is “This is what I see, and this is what you need.”, and his advice is ethically appropriate.2 A consultant providing a second Am J Orthod Dentofacial Orthop 2012;142:746 0889-5406/$36.00 Copyright Ó 2012 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2012.08.019
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opinion should also explain that there are many ways to approach an orthodontic problem. Criticism initiates confusion, undermines confidence in both the accuser and the accused, and can catalyze legal action. The AAO Principles of Ethics and Principles of Professional Conduct, Section I., E, states the following. A second opinion . . . must be honest and focus on the facts presented. It is unethical to propound a specific technique, philosophy, training or ability as superior without acknowledging that each orthodontist uses different techniques based on training and experience, and that the second opinion is based on an orthodontist’s individual perspective.3
Although professionals have a sense of duty to assist colleagues who are compromised in judgment or clinical skills for various reasons, the highest priority must be our patients' welfare. A patient must not feel that his or her problems are ignored. In addition, communication with the previous provider is essential. If communication fails to disclose unapparent circumstances about the compromised treatment, the incompetent provider should be discreetly reported to the state dental society for investigation.4 In response to James’s mother, who demanded to know why the other orthodontist failed to mention the need to address that ectopic first molar, you should stand by your conviction that the issue must be addressed. But you should also seek James’s mother’s permission to contact the first orthodontist to explain your recommendations. Under no condition should you criticize the quality of his advice, especially in the presence of James and his family. As Reagan and Parkinson might also say, “Thou shall not speak ill of any fellow orthodontist.” REFERENCES 1. http://en.wikipedia.org/wiki/The_Eleventh_Commandment_(Ronald_ Reagan). Accessed April 8, 2012. 2. Jerrold L. Talking trash. Am J Orthod Dentofacial Orthop 2011;140: 444-5. 3. American Association of Orthodontists. Principles of ethics and code of professional conduct, Section I., E. Adopted May 1994; amended through May 2010. Available at: http://www.aaomembers.org/ MyAAO/Goverance/upload/Principles-of-Ethics-as-ammendedthrough-2009.pdf. Accessed May 20, 2012. 4. Rule J, Veatch RM. Ethical questions in dentistry. In: Bywaters L, Harmon L, editors. Fidelity: obligations of trust and confidentiality. 2nd ed. Chicago: Quintessence; 2004. p. 138.
“Thou shalt not speak ill . . .” Peter M. Greco Philadelphia, Pa
I
t’s another second-opinion evaluation of a patient who was initially examined by the busiest orthodontist in town. Ten-year-old James comes with his mother upon referral from his neighbor. The recommendation of the initial orthodontist was that treatment was not yet indicated, but James’s mother was certain that the orthodontist’s evaluation was so hurried that it was incomplete. When she called to make the appointment, she said, “Dr Jones’s office was like a factory.” Your clinical examination reveals a midtransitional dentition with immobility of all deciduous molars and canines. Although the left first permanent molar is fully erupted, you notice that the contralateral permanent molar is infraoccluded. A panoramic radiograph confirms ectopy of the maxillary right first permanent molar. After you explain the problem, the mother pointedly asks, “Why did the other orthodontist tell me that James needed no treatment?” A moment that seems like an eternity follows. During Ronald Reagan’s 1966 race for governor of California, Republican Party chairman Gaylord B. Parkinson said, “Thou shalt not speak ill of any fellow Republican.”1 The adage was intended to prevent fragmentation of the Republican Party that might damage its profile in the election. Such loyalty to colleagues in politics is rare. The fraternal relationship between professional colleagues transcends age and geography. Loyalty to educational institutions and among classmates forms a bond that alumni organizations nurture and perpetuate. Ethically speaking, the principle of fidelity represents an act of loyalty, since it supports the keeping of promises. The question of fidelity or loyalty becomes amplified when an orthodontist is confronted by a demand for judgment of another practitioner’s recommendations or treatment results. Although treatment philosophies can differ, frank criticism of a colleague is unethical and reflects poorly on all involved persons. Negativism therefore should be avoided. Comments in a second-opinion evaluation should be confined to the here and now, and not what should have, could have, and would have been done. Dr Laurance Jerrold’s suggested response is “This is what I see, and this is what you need.”, and his advice is ethically appropriate.2 A consultant providing a second Am J Orthod Dentofacial Orthop 2012;142:746 0889-5406/$36.00 Copyright Ó 2012 by the American Association of Orthodontists. http://dx.doi.org/10.1016/j.ajodo.2012.08.019
746
opinion should also explain that there are many ways to approach an orthodontic problem. Criticism initiates confusion, undermines confidence in both the accuser and the accused, and can catalyze legal action. The AAO Principles of Ethics and Principles of Professional Conduct, Section I., E, states the following. A second opinion . . . must be honest and focus on the facts presented. It is unethical to propound a specific technique, philosophy, training or ability as superior without acknowledging that each orthodontist uses different techniques based on training and experience, and that the second opinion is based on an orthodontist’s individual perspective.3
Although professionals have a sense of duty to assist colleagues who are compromised in judgment or clinical skills for various reasons, the highest priority must be our patients' welfare. A patient must not feel that his or her problems are ignored. In addition, communication with the previous provider is essential. If communication fails to disclose unapparent circumstances about the compromised treatment, the incompetent provider should be discreetly reported to the state dental society for investigation.4 In response to James’s mother, who demanded to know why the other orthodontist failed to mention the need to address that ectopic first molar, you should stand by your conviction that the issue must be addressed. But you should also seek James’s mother’s permission to contact the first orthodontist to explain your recommendations. Under no condition should you criticize the quality of his advice, especially in the presence of James and his family. As Reagan and Parkinson might also say, “Thou shall not speak ill of any fellow orthodontist.” REFERENCES 1. http://en.wikipedia.org/wiki/The_Eleventh_Commandment_(Ronald_ Reagan). Accessed April 8, 2012. 2. Jerrold L. Talking trash. Am J Orthod Dentofacial Orthop 2011;140: 444-5. 3. American Association of Orthodontists. Principles of ethics and code of professional conduct, Section I., E. Adopted May 1994; amended through May 2010. Available at: http://www.aaomembers.org/ MyAAO/Goverance/upload/Principles-of-Ethics-as-ammendedthrough-2009.pdf. Accessed May 20, 2012. 4. Rule J, Veatch RM. Ethical questions in dentistry. In: Bywaters L, Harmon L, editors. Fidelity: obligations of trust and confidentiality. 2nd ed. Chicago: Quintessence; 2004. p. 138.