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ETHICALMOMENT
HOW CAN I ETHICALLY HANDLE A PATIENTS REQUEST FOR WHAT I CONSIDER A SUBSTANDARD TREATMENT OPTION?

decisions and to select an alternative plan. Section 1 of the ADA Code,1 Patient Autonomy, states:
The dentist has a duty to respect the patients rights to self-determination and confidentiality. This principle expresses the concept that professionals have a duty to treat the patient according to the patients desires, within the bounds of accepted treatment. Under this principle, the dentists primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patients needs, desires and abilities .

One of my patients recently had to undergo the extraction of a mandibular second premolar because of periodontal disease. It was an abutment for a three-unit fixed partial denture (FPD), so she also lost the first molar pontic. She refuses any treatment for her periodontal condition, and her remaining posterior teeth in that quadrant are not periodontally strong enough to support a new FPD. After having reviewed all her options, she says that her dental benefit plan will cover a new fixed bridge at 100 percent and she will not accept any other treatment. She has offered to sign a waiver to get me to do the treatment. How should I handle this ethically? Your patient has a specific treatment request that your training and experience lead you to believe not only would be less than optimal, but also may very well prove to be harmful in the long run. This all-toocommon problem presents you with conflicts among a number of ethical principles. Many of the principles found in the American Dental Association Principles of Ethics and Code of Professional Conduct1 (ADA Code) address portions of the situation that has created your dilemma. You obviously want to provide the best care for your patient. This is in line with the principle of Beneficence, found in Section 3 of the ADA Code,1 which states, in part:
[T]he dentists primary obligation is service to the patient and the public-at-large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient.

However, while allowing the patient to exercise the right of self-determination, the agreed-on treatment plan should be within the bounds of accepted treatment. This is clearly stated in the ADA Code1 section mentioned above and inferred in Section 2, Nonmaleficence, which tells us:
The dentist has a duty to refrain from harming the patient. Under this principle, the dentists primary obligations include keeping knowledge and skills current, knowing ones own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate.

Your desire to deliver competent care to your patient must be coupled with your patients right to participate in treatment

It appears that you have educated your patient about the etiology of periodontal disease and the risks of forgoing treatment. In respecting her decision to decline treatment, you should seriously consider having her sign a written informed refusal form for periodontal treatment, acknowledging her understanding of the risks of declining the recommended treatment. As a professional, you have education and training that your patient does not have, which allow you to make more informed treatment decisions, especially in situations in which a risk of harm exists. If you were to respect her wishes, your concern is that the treatment alternative she is requesting actually may promote more rapid loss of the remaining teeth in that quadrant. Does her desire for specific care that, in your opinion, constitutes substandard care override your ethical obligation to do no harm? Can your patient waive this obligation? Let us again look at the principle of Nonmaleficence, this time under Section 2A, Education.

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Copyright 2008 American Dental Association. All rights reserved.

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There it states that [t]he privilege of dentists to be accorded professional status rests primarily in the knowledge, skill and experience with which they serve their patients and society.1 You may be ethically bound to refuse a patients request for care that your training has taught you may cause problems. Keep in mind that your patients full coverage for a specific procedure under her benefit plan is no reason to alter your treatment recommendations to the extent that the treatment may itself cause harm. Section 3 of the ADA Code,1 Beneficence, helps us appreciate that: Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patients welfare first. The treatment options you present should not be limited by whether or not there is third-party coverage or whether or not you have signed on with a third-party payer. When dealing with patients who not only decline treatment, but also ask you to compromise your professional judgment in rendering treatment, it is in your best interest, as stated earlier, to ask the patient to sign a written informed refusal form. This should be done even, and perhaps especially, when you are continuing to retain the patient in your practice. Consult applicable law. Your personal

attorney, insurance carrier and constituent dental society can best advise you in these matters. Remember that even your best efforts to educate patients may fall on deaf ears. However, you should not accept the patients attempt, written or otherwise, to give you permission to provide substandard care. Unless the teeth are sound enough to support a bridge, you should not be required to provide this patient with one. Sometimes it takes a firm stand to give patients a wake-up call. Rod B. Wentworth, DDS, practices general dentistry in Bellevue, 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 ADA 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 ethics@ada.org. 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 all 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. Principles of ethics and code of professional conduct, with official advisory opinions revised to January 2005. Chicago: American Dental Association; 2005.

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JADA, Vol. 139

http://jada.ada.org

July 2008

Copyright 2008 American Dental Association. All rights reserved.