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WHAT IS THE ETHICAL COURSE OF ACTION FOR A DENTIST WHOSE PATIENT'S PREVIOUS DENTIST MAY HAVE TREATED THE WRONG TOOTH?
PERSPECTIVES
ETHICAL
MOMENT
ETHICALMOMENT WHAT IS THE ETHICAL COURSE OF ACTION FOR A DENTIST WHOSE PATIENT’S PREVIOUS DENTIST MAY HAVE TREATED THE WRONG TOOTH?
Q
A patient came to my practice complaining of continuing pain and sensitivity in her lower right molar area. Her chief complaint was that she cannot chew on that side, and it is sensitive to cold. The patient was irritated with her previous dentist, who placed a crown on tooth no. 30. She stated that she had pain and sensitivity in the area that was not resolved by the treatment. She returned to the dentist several times but was told nothing was wrong and her crown was fine. My examination revealed she has a porcelain-fused-to-metal crown on tooth no. 30 that appears to have been done well; the occlusion is not high, the margins are secure and closed, and the contacts and contours are correct. A periapical radiograph revealed no pathology and confirmed my clinical examination findings. As I continued, however, I noticed that tooth no. 31 had several vertical cracks and an occlusal amalgam that is corroded and appears to be leaking at the margins. I tested the tooth by blowing air on it and isolated pressure on the tooth by having the patient bite on a cottontipped applicator. The patient grabbed her cheek and expressed pain with each test. My diagnosis was cracked-tooth syndrome on tooth no. 31 and probably an irreversible pulpitis. When I explained my findings to the patient, she exclaimed, “That dentist did the wrong tooth! I knew he was not a good dentist. He never even asked me if I wanted to have a crown. I want to sue him and I want you to help me.” How do I begin to make sense of all this and arrive at a solution that will satisfy my patient while enabling me to avoid criticizing my colleague unjustifiably?
A
Guidance with regard to this dilemma can be found in the American Dental Association Principles of Ethics and Code of
Professional Conduct1 (ADA Code). “The ADA Code is, in effect, a written expression of the obligations arising from the implied contract between the dental profession and society.”1 At issue are the principles of patient autonomy, beneficence and justice. Undergirding these principles is the primary goal of benefiting the patient.1 Section 4, Principle of Justice, reminds us that the dentist “has a duty to treat people fairly.”1 This applies to patients as well as to colleagues. Therefore, before making an assumption that a colleague has performed inferior work, you need to make sure that any criticism is justified. Section 4.C, Justifiable Criticism, addresses this issue: Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Patients should be informed of their present oral health status without disparaging comment about prior services.1
Though the situation may appear suspect, you have a duty to refrain from disparaging your colleague and, according to Advisory Opinion 4.C.1, Meaning of “Justifiable,” may need to consult “with the previous treating dentist(s), in accordance with applicable law, to determine under what circumstances and conditions the treatment was performed.”1 You are not aware of the circumstances involved in the previous treatment and therefore cannot comment on the dentist or the work done without more information from the source. However, if there is evidence of negligence or faulty treatment, you have a duty to report it to your component or constituent dental society.1 Now that you have accepted the patient into your practice, Section 3, Principle of Beneficence (“do good”), requires you to “promote the patient’s welfare.”1 In this case, you must attempt to resolve her problem with the proper treatment. Section 1, Principle of Patient Autonomy (“self-governance”), states that your patient has the right to choose the treatment she will receive. Involving her in all aspects of treatment decisions will create a relationship of trust, as articulated in Section 1.A, Patient Involvement. This might be particularly important to her, your relation-
JADA 143(8)
http://jada.ada.org
Copyright © 2012 American Dental Association. All rights reserved.
August 2012 917
PERSPECTIVES
ETHICAL
MOMENT
ship with her, and the profession more generally given her anger and expressed distrust of her previous dentist. Contacting the patient’s previous dentist to determine the conditions and circumstances under which he or she performed the treatment not only would be good practice but also would be ethical practice. In addition, Section 1.B, Patient Records, states that “[u]pon request of a patient or another dental practitioner, dentists shall provide any information in accordance with applicable law that will be beneficial for the future treatment of that patient.”1 Collecting this information will help in determining what happened and whether, in fact, the patient’s previous dentist treated the wrong tooth. Assessing this information may become particularly important if you are asked to make a public statement. Section 4.C, Justifiable Criticism, requires that “[d]entists issuing a public statement with respect to the profession shall have a reasonable basis to believe that the comments made are true.”1 The obligation to initiate any reporting arises if you believe that the dentist acted unethically. Most ethical dilemmas involve more than one solution, and the solution depends on the circumstances and personalities of the people involved. Contacting the patient’s previous dentist can help guide your decision with respect to reporting his or her behavior. Should the dentist recognize the problem and want to provide the proper treatment to the patient, this may be beneficial not only to the patient and the dentist but also to the entire profession, because it reflects his or her commitment to do what is best for the patient. If contacting the dentist is not an option, your obligation is to explain the situation to your patient and provide her with the treatment options so she is free to make an autonomous and informed decision. Her options might include endodontic treatment and placement of a crown on tooth no. 31, which you can perform, or you can refer her to a specialist. Alternatively, she might decide to have the tooth extracted, although this
918 JADA 143(8)
http://jada.ada.org
would be an extreme solution. In any case, the patient must make the decision regarding her treatment on the basis of her values and individual circumstances. Using the ADA Code as a guide and listening to and communicating with your patients can solve many problems and help you determine the best course of action to take. In this scenario, allowing the patient to make the final decision regarding her treatment once all options have been explained to her, including the possibility of having the previous dentist address the issue, is the best way to resolve her immediate problem. A more delicate issue is discussing with the patient her previous treatment. In addition, the matter of reporting the dentist’s behavior and the possibility of the patient’s initiating legal action against the previous dentist require careful consideration. If evidence of negligence exists, you must report it to the component or constituent dental society and the appropriate reviewing agency, usually your state dental board. If the patient chooses to pursue legal action and you are called to report, your duty is to report what you see and nothing else. ■ Laura Williams, DMD, practices general dentistry in Wenatchee, Wash., and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail “[email protected]”. The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA. Address reprint requests to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, Ill. 60611. 1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. www.ada.org/sections/ about/pdfs/code_of_ethics_2012.pdf. Accessed May 23, 2012.
August 2012
Copyright © 2012 American Dental Association. All rights reserved.
ETHICAL
MOMENT
ETHICALMOMENT WHAT IS THE ETHICAL COURSE OF ACTION FOR A DENTIST WHOSE PATIENT’S PREVIOUS DENTIST MAY HAVE TREATED THE WRONG TOOTH?
Q
A patient came to my practice complaining of continuing pain and sensitivity in her lower right molar area. Her chief complaint was that she cannot chew on that side, and it is sensitive to cold. The patient was irritated with her previous dentist, who placed a crown on tooth no. 30. She stated that she had pain and sensitivity in the area that was not resolved by the treatment. She returned to the dentist several times but was told nothing was wrong and her crown was fine. My examination revealed she has a porcelain-fused-to-metal crown on tooth no. 30 that appears to have been done well; the occlusion is not high, the margins are secure and closed, and the contacts and contours are correct. A periapical radiograph revealed no pathology and confirmed my clinical examination findings. As I continued, however, I noticed that tooth no. 31 had several vertical cracks and an occlusal amalgam that is corroded and appears to be leaking at the margins. I tested the tooth by blowing air on it and isolated pressure on the tooth by having the patient bite on a cottontipped applicator. The patient grabbed her cheek and expressed pain with each test. My diagnosis was cracked-tooth syndrome on tooth no. 31 and probably an irreversible pulpitis. When I explained my findings to the patient, she exclaimed, “That dentist did the wrong tooth! I knew he was not a good dentist. He never even asked me if I wanted to have a crown. I want to sue him and I want you to help me.” How do I begin to make sense of all this and arrive at a solution that will satisfy my patient while enabling me to avoid criticizing my colleague unjustifiably?
A
Guidance with regard to this dilemma can be found in the American Dental Association Principles of Ethics and Code of
Professional Conduct1 (ADA Code). “The ADA Code is, in effect, a written expression of the obligations arising from the implied contract between the dental profession and society.”1 At issue are the principles of patient autonomy, beneficence and justice. Undergirding these principles is the primary goal of benefiting the patient.1 Section 4, Principle of Justice, reminds us that the dentist “has a duty to treat people fairly.”1 This applies to patients as well as to colleagues. Therefore, before making an assumption that a colleague has performed inferior work, you need to make sure that any criticism is justified. Section 4.C, Justifiable Criticism, addresses this issue: Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Patients should be informed of their present oral health status without disparaging comment about prior services.1
Though the situation may appear suspect, you have a duty to refrain from disparaging your colleague and, according to Advisory Opinion 4.C.1, Meaning of “Justifiable,” may need to consult “with the previous treating dentist(s), in accordance with applicable law, to determine under what circumstances and conditions the treatment was performed.”1 You are not aware of the circumstances involved in the previous treatment and therefore cannot comment on the dentist or the work done without more information from the source. However, if there is evidence of negligence or faulty treatment, you have a duty to report it to your component or constituent dental society.1 Now that you have accepted the patient into your practice, Section 3, Principle of Beneficence (“do good”), requires you to “promote the patient’s welfare.”1 In this case, you must attempt to resolve her problem with the proper treatment. Section 1, Principle of Patient Autonomy (“self-governance”), states that your patient has the right to choose the treatment she will receive. Involving her in all aspects of treatment decisions will create a relationship of trust, as articulated in Section 1.A, Patient Involvement. This might be particularly important to her, your relation-
JADA 143(8)
http://jada.ada.org
Copyright © 2012 American Dental Association. All rights reserved.
August 2012 917
PERSPECTIVES
ETHICAL
MOMENT
ship with her, and the profession more generally given her anger and expressed distrust of her previous dentist. Contacting the patient’s previous dentist to determine the conditions and circumstances under which he or she performed the treatment not only would be good practice but also would be ethical practice. In addition, Section 1.B, Patient Records, states that “[u]pon request of a patient or another dental practitioner, dentists shall provide any information in accordance with applicable law that will be beneficial for the future treatment of that patient.”1 Collecting this information will help in determining what happened and whether, in fact, the patient’s previous dentist treated the wrong tooth. Assessing this information may become particularly important if you are asked to make a public statement. Section 4.C, Justifiable Criticism, requires that “[d]entists issuing a public statement with respect to the profession shall have a reasonable basis to believe that the comments made are true.”1 The obligation to initiate any reporting arises if you believe that the dentist acted unethically. Most ethical dilemmas involve more than one solution, and the solution depends on the circumstances and personalities of the people involved. Contacting the patient’s previous dentist can help guide your decision with respect to reporting his or her behavior. Should the dentist recognize the problem and want to provide the proper treatment to the patient, this may be beneficial not only to the patient and the dentist but also to the entire profession, because it reflects his or her commitment to do what is best for the patient. If contacting the dentist is not an option, your obligation is to explain the situation to your patient and provide her with the treatment options so she is free to make an autonomous and informed decision. Her options might include endodontic treatment and placement of a crown on tooth no. 31, which you can perform, or you can refer her to a specialist. Alternatively, she might decide to have the tooth extracted, although this
918 JADA 143(8)
http://jada.ada.org
would be an extreme solution. In any case, the patient must make the decision regarding her treatment on the basis of her values and individual circumstances. Using the ADA Code as a guide and listening to and communicating with your patients can solve many problems and help you determine the best course of action to take. In this scenario, allowing the patient to make the final decision regarding her treatment once all options have been explained to her, including the possibility of having the previous dentist address the issue, is the best way to resolve her immediate problem. A more delicate issue is discussing with the patient her previous treatment. In addition, the matter of reporting the dentist’s behavior and the possibility of the patient’s initiating legal action against the previous dentist require careful consideration. If evidence of negligence exists, you must report it to the component or constituent dental society and the appropriate reviewing agency, usually your state dental board. If the patient chooses to pursue legal action and you are called to report, your duty is to report what you see and nothing else. ■ Laura Williams, DMD, practices general dentistry in Wenatchee, Wash., and is a member of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail “[email protected]”. The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA. Address reprint requests to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, Ill. 60611. 1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. www.ada.org/sections/ about/pdfs/code_of_ethics_2012.pdf. Accessed May 23, 2012.
August 2012
Copyright © 2012 American Dental Association. All rights reserved.