ETHICS IN ORTHODONTICS

Informed consent or informed refusal?

Peter M. GrecoPhiladelphia, Pa

Karen is an anesthesiology resident and your lastpatient of the week. Her chief concern is theirregularity of her maxillary incisors. She

describes her experience of prolonged, comprehensiveorthodontic therapy as an adolescent. She says thatshe had “4 years of treatment with 8 teeth extractedand a night brace—the works!” She admits that the resultwas never ideal, even immediately after treatment.

Her history does not surprise you. Her excessive facialconvexity and vertical maxillary excess, includingabundant gingival display and long lower facial height,are evident the moment you meet her. A 5-mm anterioropen bite with maxillary constriction is obvious. Youcomplete your examination and suggest bimaxillarysurgery as the ideal way to address the problem, includ-ing segmental LeFort and mandibular advancementprocedures. As you begin to advise Karen that assess-ment of diagnostic records is needed to verify your initialimpression, she stares back at you defiantly and exclaims“No way!” She says that she sees many of those surgeriesin the operating room and “no surgeon will do that tome!” She also politely declines fixed therapy but assertsthat she will be highly compliant with esthetic aligners.You patiently explain the shortcomings of suchcorrection, but she says that she doesn't care. “No bracesand no surgery,” she retorts.

We are well aware that informed consent is essentialto orthodontic treatment delivery. Informed consent isa hallmark of the ethical principle of autonomy, as wegive our patients sufficient information for them tochoose a treatment plan. Our intent is to disclose therisks and benefits of treatment, as well as availableoptions, to address each patient's concerns. Alsoincluded should be the consequences of foregoingtreatment altogether. In providing autonomy, an ortho-dontist should strive to bridge the gap between theprofessional's perspective of the problem and thepatient's objectives of treatment by building a consensusbetween them.1 Contrast autonomy with the principle of

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paternalism in which the practitioner decides what isbest for a patient, irrespective of the patient's input.

Despite our efforts to emphasize the value of an idealtreatment plan, some patients choose a plan that is lessthan ideal—possibly one that might be prone to instabil-ity or could fail to address functional deficiencies. If weagree to treat that patient, and the patient accepts theshortcomings of his or her treatment choice, we aretreating under informed refusal.

Informed refusal can occur for various reasons. Pre-vious experiences, prejudices, religious beliefs, culturallore, financial limitations, phobias, or simply a whimmight be sufficient grounds for a patient to reject theideal option and choose a significantly compromisedalternative.2 An orthodontist must be introspective tobe certain that the risks, benefits, and options wereexplained clearly and thoroughly in nonprejudicial, layterms. Time for free dialog between the practitionerand the patient must be allowed to explore the patient'squestions and concerns. A practitioner should never viewa patient's rejection of an ideal treatment plan asa personal affront.2 And a practitioner has full autonomyto refuse to provide therapy if the limitations imposed bythe patient jeopardize his or her dental health.

The most difficult aspect of providing informed con-sent can be the determination of the degree of detail dis-closed for each treatment option. Although one shouldbe as thorough as possible, excessive details or manytreatment choices can create confusion—perhaps evenbewilderment—resulting in the patient's ambivalencetoward treatment.

What do you say to Karen if she severely limits yourtreatment options? The ultimate responsibility ofobtaining informed consent or accepting informedrefusal is the orthodontist's obligation. If informedrefusal is the patient's choice, the next choice is yours.

The author acknowledges the great influence of thebook Dental Ethics2 in the development of this editorial.

REFERENCES

1. Ackerman JA, Proffit W. Communication in orthodontic treatmentplanning: bioethical and informed consent issues. Angle Orthod1995;65:253-61.

2. Weinstein BD. Informed consent and refusal. In: Cooke DB, editor.Dental ethics. Philadelphia: Lea and Febiger; 1993. p. 76-7.