Impolrtant Notice

This is one of a series of ethical dilemmas published in the Texas Dental Journal between 1993 and 2005. Thelead author of these dilemmas, Dr. Thomas K. Hasegawa, died tragically in 2005. The dilemmas remain animportant legacy for dentistry.

Format

Each ethical dilemma was originally introduced in one issue of the Texas Dental Journal with thequestion, "What would you do?" The more expansive analysis of the dilemma was presented in asubsequent issue. The second page of this file depicts the cover of the issue containing the analysis ofthe dilemma, not the issue containing the briefer introduction to the dilemma. The ethical dilemmaswere compiled for digital use by the American College of Dentists in 2008.

Purpose

This ethical dilemma and the other dilemmas in the series are only meant to further your knowledge andunderstanding of dental ethics by presenting, discussing, and analyzing hypothetical ethical dilemmasthat may occur in dental settings. The dilemmas are not intended to: a) provide legal advice; b) provideadvice or assistance in the diagnosis or treatment of dental diseases or conditions; or c) provide adviceor assistance in the management of dental patients, practices, or personnel.

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To use the digital ethical dilemmas in the series, all or part, you must first agree to the Terms of Usespecified at https://www.dentalethics.org/termsofuse.shtml. By using this dilemma, or any in the series,you are affirming your acceptance of said Terms of Use and your concurrence with the Purposepresented immediately above.

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American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

Version I2008

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.- ,. .., .. .,. ... . ,. .. .. ., ..., . . . -. .,. . -, . ... . . ...,. . - . . ,. . - ... , ...- -,.. ,., ,. . ... .. -,- .. .. ,. .- f::f-. . .. .. . ... -.. .. ....., .. .brushing. Also, his face felt slightly swollen in the area, although there was no pain currently from the teeth or gums.He had painful episodes that he attributed to a toothache in the same area when the bleeding first started~ His friendstold him he probably had "pyorrhea" and needed his teeth "scraped." One of his employees gave him your name.

Your examination reveals firmness of the lymph nodes in the left neck, but the nodes are not tender. Intraorally, allthe soft tissues appear within normal limits, except for the gingival on the mandibular left, In the area of the first molarthere is a raised, somewhat papillary red and white irregular lesion of lx2 cm that is firm on palpation. The first molarappears to be healthy except for a Class III mobility as the tooth is compressible. His periodontal condition is normalin the other quadrants. Radiographs show complete bony destruction that extends to the apices from the mesial of thesecond molar to the mesial root of the first molar. The teeth appear to be "floating in air", as the borders of the lesionare neither sclerotic or defined. The last time you saw this type of lesion was when you were in dental school 5 yearsago and you suspect a possible malignancy.

Tom asks: "Is it cancer? My father died of mouth cancer when he was 50." He admits to you that his fear of the dentistwas the result of seeing his father suffer for six months before he died. He again says, "Tell me, is this cancer? I don'tknow what I will do if it is cancer!"

You reassure Tom that although the lesion appears suspicious, a biopsy is necessary to establish the diagnosis.You also mention the name of an oral surgeon who you recommend to perform the procedure. Tom is obviously shakenand implores you to do the biopsy and be the doctor to discuss the findings - he trusts you even if he is phobic aboutdentists. You have performed a number of biopsies in the past and his request is not unreasonable.

The incisional biopsy surgery went without complications, other than Tom requiring preoperative sedation. The.: . .~. . . ~. ,fl ~ . . .. ~ . . .. f . . . L. . . f .. , -. , .:. .+.1l~ . rfl~ .c . . s . f . . . &~~ -- sf . f . . ~~. f .:. .:~ .. . & +f ~ f .~ . .~~ f ~&& &:~~s . ~ f . ~ \f?l . . .

.,--..,-., .',- - ,.. ' .- '.,- -. ,..- -.-r', - . . . - - - - , .- - . . r`;i::f - ' - ,- ` ' ' - ' "' ' "' ` '-~ - ' ` " " ` ' - - " - "-`-.. - "J -You immediately call the oral pathologist, Dr. Grimes, who confirms the diagnosis and explains the grave prognosis

of Toms malignancy. Dr. Grimes explains that even with radical surgery, radiation therapy and chemotherapy, the five-year survival rate is estimated at 10% to 30010. You then call to schedule Tom for a consultation and his spouse, Ann,answers the phone. Ann tells you that Tom is so frantic that she is worried that he may do something "desperate" if heis told he has a malignancy. She pleads with you not to tell him now, even if it is malignant, but to delay this stress a fewdays. "Tell him you need a second opinion, another lab test ̀ anything. If you tell him now," she exclaims again "Ifm

not sure what he will dot" You make the consultation appointment for Tom for the following day and consider what youwill do.

You are now faced with an ethical dilemma. Check the following course(s) of action you would take in this case andmail, fax this page, E-mail your recommendation, or send a note as instructed below:1. ~______ at the consultation appointment, inform Tom that that he has oral cancer, what generally needs to be done,

but do not mention the poor prognosis;2. at the consultation appointment, inform Tom that he has oral cancer, what generally needs to be done, and

discuss the poor prognosis with him;3. follow his wife's advice and call Tom to inform him that you need a (fictitious) "second opinion" and that this

will take another week;4. you call the oral pathologist, Dr. Grimes again to ask if he will break the news to Tom;5. call Tom and ask him to see an oncologic surgeon to discuss the status of his biopsy; or6. other alternative (please describe):

| SEND YOUR RESPONSE BY July 8,lgg6 ATTENTION: Dr. Thomas K. Hasegawa, Jr., Department of General| eit__ryyor ,_,..COt .II ~g ~ ~of ,._.fDen. .tistry, P.O. Box 660677 Dallas, TX 75266-0677, fax to (214) 828-8052, or E-mail to:

"Bad News Bearers"Response to Ethical Dilemma #33

Mr. Tom Allen is a new patient inyour general practice who admits being adental phobic. In fact, it has been eightyears since his last dental exam. He is 42years old and owns the hardware shop inyour town of 25,000 people. Tom says heis in good health, although is overweightand admits that he has smoked a pack-a-day for twenty years and drinks two orthree beers every day. He has a yearlyphysical, and his vitals are within normallimits. His chief complaint is that withinthe last six months, his molars on the leftside started to feel "loose" and the gumswould bleed easily on brushing. Also, hisface felt slightly swollen in the area,althoughtherewasnopaincurrentlyfromthe teeth or gums. He had painful epi-sodes that he attributed to a toothache inthe same area when the bleeding firststarted. His friends told him he probablyhad "pyorrhea" and needed his teeth"scraped." One of his employees gavehim your name.

Your examination reveals firmnessof the lymph nodes in the left neck, butthe nodes are not tender. Intraorally, allthe soft tissues appear within normallimits, except for the gingival on themandibular left. In the area of the firstmolar there is a raised, somewhat papif'lary red and white irregular lesion of 1x2cm that is firm on palpation. The firstmolar appears to be healthy except for aClass III mobility, as the tooth is com-pressible. His periodontal condition isnormal in the other quadrants. Radio-graphs show complete bony destructionthat extends to the apices from the mesialof the second molar to the mesial root ofthe first molar. The teeth appear to be"floating in air", as the borders of thelesion arc neither sclerotic or defined.

The last time you saw this type of lesion

was when you were in dental school fiveyears ago and you suspect a possiblemalignancy.

Tom asks: "Is it cancer? My fatherdied of mouth cancer when he was 50.

He admits to you that his fear of thedentist was the result of seeing his fathersuffer for six months before he died. He

again says, "Tell me, is this cancer? Idont know what I will do if it is cancer!

You reassure Tom that although thelesion appears suspicious, a biopsy isnecessary to establish the diagnosis. You

also mention the name of an oral surgeonwho you recommend to perform the pro-

cedure. Tom is obviously shaken andimplores you to do the biopsy and be thedoctor to discuss the findings - he trusts

you even if he is phobic about dentists.You have performed a number of biop-

sies in the past, and his request is not

unreasonable.The incisional biopsy surgery went

without complications, other than Tomrequiring preoperative sedation. The bi-opsy sample was wedge shaped, approxi-mately 3x5 mm taken from the buccalgingiva of the lower left first molar. Youmailed the sample to an oral pathologyservice with instructions to fax the resultsto your office. Within 24 hours, the labo-ratory faxed the results of the biopsy. TheFAX is on page 33. (NOTE: all names onthe FAX are fictitious).

You immediately call the oral pa-thologist, Dr. Grimes, who confirms thediagnosis and explains the grave progno-sis of Tom's malignancy. Dr. Grimesexplains that even with radical surgery,radiation therapy and chemotherapy, thefive-year survival rate is estimated at10% to 30%. You then call to scheduleTom for a consultation and his spouse,Ann, answers the phone. Ann tells youthat Tom is so frantic that she is worriedthat he may do something "desperate" ifhe is told he has a malignancy. She pleadswith you not to tell him now, even if it ismalignant, but to delay this stress a fewdays. "Tell him you need a second opin-ion, another lab test - anything. If youtell him now," she exclaims again, "Imnot sure what he will do! You make theconsultatl'on appointnlent for Tom forthe following day and consider what youwill do.

Dentists noted that they would: I)inform Tom that he has oral cancer, whatgenerally needs to be done, but do notmention the poor prognosis; 2) infom1Tom that he has oral cancer, what gener-ally needs to be done, and discuss theprognosis with him; and 3) after follow-ing the actions in option #I, call Tom andask him to see an oncologic surgeon oroncologist to discuss the status of his

32 I OCTOBER 1996

All names. addresses. phone numbers. and patientinformation on this report are lictitious

ORAL PATHOLOGY LABORATORY

3566 Washington St. ' Austin, TX 78756Telephone: (512) 828-8110, 8111/Telefax: (512) 828'-8306

Tom Jackson, DDS, MSDEdward Burnside II, DDS, MSDJack J. Grimes, DDS, MS

Date: 05/06/96 Path No.: D96-1778

PATHOLOGY REPORT

Patienfs Name: Allen, Tom Age: 42 Sex: M Race: C

Operated by: Dr. Thomas Smith Patient Reg. No.: 0001

Specimen: L Md. gingiva

Clinical Diagnosis: Squamous cell carcinoma

GROSS DESCRIPTION

Patient complaining of loose teeth in L Md. and bleeding gums.Asymptomatic now but pain in past. L cervical adenopathy. 1-'2cm redand white papillary lesion along #19 buccal gingiva. #19 mobile andradiographs disclose destructive lucency without cortication.

MICROSCOPIC DESCRIPTION

Histologic examination reveals a wedge of oral mucosa containing amalignant and neoplastic proliferation of poorly differentiated epithe-lium. The surface epithelium is stratified squamous in type and itdisplays areas of dysplasia with ulceration. The connective tissue hasbeen largely replaced by large islands of poorly differentiated basiloidepithelial cells showing central necrosis. The neoplasm displayssignificant mitotic activity and an invasive growth pattern. In focal areasof the neoplasm there is squamous differentiation with small amountsof keratin produced. The neoplasm extends to all surgical margins.

DIAGNOSIS - Left posterior mandibular gingiva: Basiloid squamouscell carcinoma.

COMMENT: The basiloid squamous cell carcinoma is a newlydescribed variant of oral cancer. Most patients willhave regional metastasis at the time of diagnosis andbetween a 1/3 and 1/2 of these patients will haveor will develop d~tan~ m~ s.ais.

PATHOLOGIST

TEXAS DENTAL JOURNAL / 33

lished in 1847:"(T)he physician should be the min-ister of hope and comfort to the sick;that, by such cordials to the droopingspirit, he may smooth the bed ofdeath, revive expiring life, and coun-teract the depressing influence ofthose maladies which often disturbthe tranquillity of the most resignedin their last moments. The life of asick person can be shortened notonly by acts, but also by the words orthe manner of aphysician. It is, there-fore, a sacred duty to guard himselfcarefully in this respect, and to avoidall things which have a tendency todl'scourage the patient and to depresshis spirits (3)."

The Code reveals two central as-sumptions about the power and the privi-lege of the physician. First, there is theassumption that the patients life can beshortened by the disclosure of discourag-ing or depressing information. It is un-clear whether this refers to the quality orquantity of life or by what yardstick thls~loss is measured. There are no researchstudies that can account for these variables.Second, the admonitionto"avoidall things"thatmay discourage ordepress thepatientsspirit provides nearly limitless justifica-tion for withholding disclosure.

Whll~ e the Code recognized the needfor disclosure, it did permit some flexibil-ity in the manner and time frame in whicha health care provider discloses that infor-mation, depending on the mental state ofthe patient.

Can Disclosure Be Harmful?Tom Allens case focuses attention

on the relevant issues of disclosure inwhat may be a worst-case scenario fordentists:thepatientwithoralcancer.Thereis an urgency and an element of the un-known in this case. Is Tom competent tohear the diagnosis or should the dentist

heed Ann,s advice?ThephysicianandpsychoanalystJay

Katz proposes that silence, or in this us-age nondisclosure, is deeply rooted in theethos of medicine for promoting and pro-tecting the best interests of the patient (4).This has been referred to as the benefi-cencemodelofmoralresponsibilitywherethe physician seeks to create the greaterbalance of good over harm for the patient.The roots of this model are from ancientGreece and derive from the claim by aprofession that it knows what is in the bestinterest of those that are served (5). Is it inToms best interest to disclose informa-tion about his malignancy if it results inphysical or psychological harm, or evensuicide? Is a primary ethical obligation to"do no harm" upheld if harm to the patientresults from the disclosure? Katz assertsthat the question, should dire informationbe shared with the patient, has dividedmedicine for centuries, with the majorityof physicians siding with nondisclosure.

None of the respondents to the casechose to heed Anns advice and deceiveand delay conveying the results of thebiopsy. Advice by respondents included"utilize a team" to help the patient copewith the disease, have counseling avail-able or offer support by clergy~ One den-tist chose to have the consultation withTom in his physicians office with thedentist present. Others chose to refer Tomto an oncologist after the initial consulta-tion to continue his care.

ConclusionDentists are faced with disclosing

information to patients about serioushealth concerns, as in the case of TomAllens malignancy. The problems thatface physicians and dentl'sts regarding thewithholding of, or disclosing, informa-tion to the patient are simll'ar. In deferenceto Toms wife, while a brief delay may beappropriate, Toms medical conditiondemands quick action. The dentists obli-

gation to disclose the diagnosis is

imperative.

1.

2.

3.

4.

5.

Foundations in legal theory. In: FadenRR, Beauchamp TL, eds. A historyand theory of informed consent. NewYork: Oxford University Press,1986:35-39.Exceptions to the legal requirements:emergency, waiver and therapeuticprivilege. In Appelbaum PS, LidzCW and Meisel A, eds. Informedconsentlegaltheoryandclinicalprac-tice. New York: Oxford UniversityPress, 1987:72-9.Code of Ethics of the American Medi-cal Association (adopted May, 1984),Chapter I , Art. I, Sec. 4.Physicians and patients. In: Katz J.ed. The silent world of doctor andpatient. New York: Free Press, 1984:17-19.McCullough LB. Ethics in dentalmedicine: a framework for moralresponsibility in dental practice. JDent Educ 1985;49(4):219-224.

EDITOR'S COMMENT: Responses tothe ethical dilemmas are views of thecontrl~butors and consultants and notBaylor College of Dentistry, the NationalCenter for Policy Analysis or the TexasDental Association. Dr. John Wright isthe Director of Pathology in the Depart-ment of Diagnostic Sciences at BaylorCollege of Dentistry. Address your com-ments to Dr. Thomas K. Hasegawa, Jr.Department of General Dentistry, BaylorCollege of Dentistry. P.O. Box 660677,Dallas, TX 75266-0677, fax to (214) 828-8952, or E-mail to: tk.hasegawa@baylordallas.edu III

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34 / OCTOBER 1996