Bad Outcomes and Bad Work
Sandra Stuart, a thirty-six-year-old corporate loan officer for a large bank, feels discomfort around a three-unit bridge placed by Dr. Frances Singer eight weeks earlier. Ms. Stuart calls Dr. Singer’s office. A recorded message says Dr. Singer is on vacation and another dentist is taking her calls and gives a phone number. There is no answer at that number, however, and no way to leave a message either. So Sandra opens the telephone book and calls the first female dentist she finds, Maria Alverez, DMD, to explain her discomfort and concern that the bridge seems to be moving.
Upon examination, Dr. Alverez finds that the bridge is loose and also has open margins. The gums are inflamed around the abutment teeth and under the pontic; there is no other inflammation anywhere else in the mouth or any signs of carious lesions or other restorations. Dr. Alverez asks Ms. Stuart, “Was this bridge permanently or temporarily cemented? Do you know?”
“I had a temporary bridge in there when it was being made,” says Ms. Stuart. “After Dr. Singer put it in, I didn’t think I needed to come back about it unless it gave me problems. Up until a week ago it felt fine. She certainly didn’t tell me it was temporary, and I’ve completely paid for it.”
“Then it was probably permanently cemented,” says Dr. Alverez.
“Is that a problem?” asks Ms. Stuart.
“Sometimes a dentist will temporarily cement a new bridge to see if it causes any problems before cementing it permanently. It depends on the situation and how the dentist wants to handle it. Both approaches are acceptable. So, there’s no problem in Dr. Singer’s having cemented it permanently. That’s one standard way of doing it.”
“But why is it moving around? If she intended it to be permanent, why is it loose?” asks Ms. Stuart. “And why am I feeling soreness right in the same spot?”
“The gum tissue is inflamed along that whole section,” says Dr. Alverez. “It’s very likely that the bridge is causing the inflammation, especially since you don’t have any gum inflammation elsewhere in your mouth. I’d like to try removing the bridge—it looks like I easily can—to see if I can figure out what’s going on there, if that’s OK with you. Once I know more about what’s going on we can talk a bit more about various options. I can then re-cement it, permanently or temporarily, depending on what I find when I am done. Would that be all right?”
“Yes, please do whatever you think will help,” says Ms. Stuart. “I’ve been avoiding chewing on that side for nearly a week and I really want it fixed. Does it look like it was made right?”
“A lot goes into making a three-unit bridge,” says Dr. Alverez. “At first look, I think some minor adjustments may help eliminate the inflammation. It might fit better if it were a bit snugger near the gums. That may seem strange, but the gums can actually get irritated when there’s a gap between the bottom of the bridge and the gum tissue. They’re much happier when there’s no gap. I may or may not be able to fix that right here this afternoon. First, I need to remove the bridge to see how it fits onto the teeth that are holding it in place. The irritation and mobility could also be coming from some cause I haven’t seen yet. Some people, for example, are allergic to the materials used to make the bridge.”
“That’s fine,” says Ms. Stuart, “go right ahead.”
Dr. Alverez easily removes the bridge and quickly determines that the preparations are nonretentive, extremely conical with overprepared interproximal walls; she sees no signs of congenitally deformed teeth or previous extensive carious lesions. The buccal wall is underprepared, making the abutment overcontoured at the gingival margin. The anterior abutment is also very short, and the relief spacing for cementation seems excessive. She considers whether newer bonding cement might help compensate for the tooth preparations and bridge fabrication but also notices the tooth shade is brighter than the surrounding natural teeth.
It seems to Dr. Alverez that Dr. Singer did not do the best job with this bridge. Dr. Alverez assumes the bridge was fabricated at a lab rather than by Dr. Singer or someone in her office. But even if some of the overcontouring and any interproximal impingement are laboratory fabrication issues, she thinks to herself, if Dr. Singer cemented this inadequate bridge, the responsibility is hers, and there’s certainly no blaming the lab for the inadequate preparations. She ponders what to do about it. Should she tell Ms. Stuart outright that Dr. Singer made a bad bridge? And what should she do clinically, regardless of what she says about Dr. Singer? Dr. Alverez decides to first find out if Ms. Stuart can tell her anything more about the bridge than what she has already said. “Did Dr. Singer say anything more or give you any special instructions about the bridge?” asks Dr. Alverez.
“Well, she did talk to me about brushing carefully in that area and flossing regularly. I didn’t use floss before, but I’ve been brushing faithfully since I was a kid. So I started brushing in that area more carefully and flossing too. I don’t think I did anything to disturb the bridge though. It just started feeling like it was moving around one day, and pretty soon it started feeling sore there. Could I have done something to cause the problem?” asks Ms. Stuart.
This is as good an opening as Dr. Alverez is likely to get if she wants to get Dr. Singer off the hook. Should she take it, finding some way to make the problem appear to be with Ms. Stuart’s self-care? Should she just re-cement the bridge temporarily and tell Ms. Stuart to chew carefully for another ten days until Dr. Singer returns? Should she ask Ms. Stuart why she needed the bridge, what caused the tooth loss? Should she try to reach Dr. Singer to discuss the case before taking any action, including re-cementing the bridge? What ought Dr. Alverez do?
Just as everything about a profession depends on its ethical commitments, so everything about a profession depends on its expertise, which is demonstrated in the ability of its members to dependably produce good outcomes. As a consequence, when an unplanned, undesirable, less-than-adequate, or bad outcome occurs, determining what ought to be done about it can be very difficult. It is difficult enough when a dentist’s own work has an undesirable outcome, which will be discussed later in this chapter. It is even more difficult when the unplanned, undesirable, less-than-adequate, or bad outcome is the result of another dentist’s work. For our purposes here, we will first focus only on bad outcomes. We will say more later in this chapter about the differences between bad outcomes and bad work.
Most of the nine categories of dental professional obligation described in chapter 3 are relevant to determining how dentists ought to act when they are faced with another dentist’s bad outcome. The most obvious category for such a situation might seem to be Ideal Relationships between Professionals because two practitioners are involved, and the bad outcome complicates their relationship with each other and with the patient. But because a patient is also involved, the categories of dentistry’s Central Practice Values and the Ideal Relationship between dentist and patient are just as significant. The most important of the Central Practice Values in such a case will be the patient’s Oral and General Health, followed by the patient’s Autonomy. The patient’s Oral Health is important in terms of the seriousness of the bad outcome and the complexities of its correction. It is also important in that the “second dentist”—that is, the one who concludes that another dentist, the “first dentist,” has had a bad outcome—may need to provide the patient with emergency treatment, specialty treatment, or possibly even continuing treatment as the patient’s general dentist, depending on the circumstances. The patient’s Autonomy is important because both dentists must figure out how to deal with the patient in a manner properly respectful of his or her Autonomy despite the difficult situation. In a similar way, both dentists are obligated to develop as interactive a relationship with the patient as possible, an effort that is complicated because two dentist-patient relationships are involved.
The category of Ideal Relationship to the Larger Community is also involved in such a situation because of the dental profession’s commitment to the larger community that it will supervise the practice of its members so that the profession’s expertise is not misused in ways that harm patients. The profession fulfills this obligation partly by making sure dental school programs graduate well-trained practitioners, requiring practitioners to maintain and improve their skills through continuing education, and, to some extent, educating the public about good professional practice patterns. But when a bad outcome occurs, another side of this supervisory role comes into play. The second dentist must determine whether the bad outcome is the result of bad work by the first dentist.
If it is, then the second dentist must consider whether the bad work is symptomatic of a potentially harmful pattern on the part of the first dentist. When the second dentist judges this is the case, the appropriate response will ordinarily require further action, possibly contacting a dental organization’s peer review body (depending on what is legally allowed within the second dentist’s civic jurisdiction). Such professional organization peer review bodies (sometimes, but not always, independent of state-appointed “boards of examiners”) would then examine the facts of the situation and ask the same questions about the first dentist’s work that the second dentist needed to ask. The larger community would certainly judge the dental profession to have failed in its obligations if the dental profession and its individual members did not raise these questions and then follow through with appropriate action. More will be said about peer review and the supervisory role of the dental profession in chapter 13. The difficult ethical challenges involved in asking these questions about a bad outcome will be examined in the following pages.
Obviously, the norm of Competence is also involved. It applies to the first dentist, who may have practiced beyond his or her level of competence, who may have been competent to practice in a manner appropriate to the patient’s clinical situation but failed to do so, or who may have practiced in a fully competent manner but had a bad outcome occur in spite of this. The norm of Competence applies to the second dentist in two ways. The second dentist will have to determine whether the bad outcome is the result of the first dentist’s failure to practice competently—that is, whether it is an instance of bad work—as well as how serious the bad outcome is, whether it is part of a pattern of bad work and so on. In addition, the second dentist must provide competent treatment as required by the circumstances of the case. This may be emergency care or specialty treatment (if the second dentist is a specialist receiving the patient for that purpose) or temporary care for the condition resulting from the bad outcome or continuing general dental care (if the second dentist is the patient’s new general dentist of choice).
The norm of the Chief Client is relevant here because cases of this sort remind the dental community that no patient is simply a patient of one dentist. Every patient is, in a certain way, a patient of every other dentist and of the whole dental profession. This is clear not only in the supervisory role that the whole profession exercises by noting and responding correctly to bad outcomes, and especially to serious or continuous bad work, but also in connection with public health and public education considerations and the obligation to provide emergency care to those who need it.
The norm of the Relative Priority of the Patient’s Well-Being is also involved. For the second dentist must also determine how much of his or her time and effort are owed to the patient with the bad outcome, as well as how much are owed to the first dentist and what other interests may need to be set aside in the process. This norm is also involved for the first dentist, who must determine what, if anything, he or she owes the patient who has experienced the bad outcome.
The principal relevance of the norm of Integrity and Professionalism is that these sorts of situations test both dentists’ commitments to staying committed to the well-being of the patient rather than focusing on either their own needs or focusing on their respective relationships with one another. The second dentist must now deal with all these extra issues, along with a patient who is certainly going to be upset and possibly angry at what has happened. The first dentist may become upset at the suggestion that he or she has performed bad work, even if the second dentist’s judgment is that they are only dealing with a bad outcome and especially if the second dentist concludes that bad work is probably involved. It will take both dentists more than usual effort to stay true to dentistry’s ethical standards as they work through situations of this sort.
A dentist’s observation of another dentist’s bad outcome arises in two situations: (1) When the patient is chiefly another dentist’s patient and (2) when the patient is either returning to a general dentist after a second dentist has done emergency or specialty care or is first coming to a new dentist and presenting with the work of previous dentists. In the second type of situation, the second dentist—that is, the one identifying the bad outcome—is either already considered to be the patient’s regular dentist or is being considered for that role by the patient. In the first situation, however, the patient’s chief relationship is with the first dentist rather than the second dentist; the second dentist—the one who identifies the bad outcome—must therefore treat the patient as the first dentist’s patient in every respect except for the patient’s need for emergency or specialty care. This and the next four sections will focus on the ethical complexities of the first situation, when it’s another dentist’s patient. Situations of the second kind will be examined after that.
Most dentists see other dentists’ patients when those patients present for emergency treatment or come to a specialist for specialty treatment. In both cases, there is an accepted set of obligations regarding the relationships between the three parties. The American Dental Association’s Principles of Ethics and Code of Professional Conduct (hereafter ADA Code) expresses one part of this obligation very well: “If [emergency] treatment is provided, the dentist, upon completion of such treatment, is obliged to return the patient to his or her regular dentist unless the patient expressly reveals a different preference” (4.B); “The specialists or consulting dentists upon completion of their care shall return the patient, unless the patient expressly reveals a different preference, to the referring dentist, or, if none, to the dentist of record for future care” (2.B).
The second dentist should treat the patient as the first dentist’s patient in other respects as well. The second dentist must also actively work to support the relationship between the patient and the first dentist. A subsequent comment in section 4.C of the ADA Code, that the second dentist should not make “disparaging comments about prior services,” identifies the bare minimum of such support. The second dentist should also encourage the patient to connect with the first dentist regarding the patient’s contact with the second dentist and for the necessary follow-up care. The second dentist should encourage the patient to develop appropriate programs of self-care and to schedule regular visits with the first dentist. The second dentist also, ordinarily, reports to the first about treatments given, conditions observed, and so on.
This obligation of the second dentist to support the patient’s relationship with the first dentist is not just an example of mutually self-serving professional etiquette. There are sound professional-ethical reasons for this requirement. First, the patient’s Oral and General Health are better served through continuity of care by a single general dentist. Second, the Central Practice Value of Patient Autonomy is respected by supporting the patient’s choice of a primary dental caregiver along with the plan of care that the patient and the primary dentist have previously worked out. Third, the goal of achieving as interactive a relationship as possible is supported by efforts to maintain and strengthen the patient’s established relationship with his or her general dentist; this norm also supports the second dentist in making his or her relationship with the patient as interactive as possible within its limited scope.
But the presence of a bad outcome complicates this situation. This is because a bad outcome puts the achievement of each of these three benefits for the patient into question. First, an outcome would not be considered bad if it did not involve the absence or failure of a needed dental treatment or put the patient’s oral or general health at some risk. Second, the patient’s plan of care surely would not include choosing a bad outcome as such. In such a situation the first dentist may have fully informed the patient about possible bad outcomes and the patient may have consciously chosen the treatment with this risk in mind. A few moments of conversation with the patient will usually reveal if this is the case. When this is the case, the bad outcome involves no direct conflict with the patient’s Autonomy. But when it is not, then something has happened that the patient has not chosen. A subtle question then arises about how each dentist is to properly respect the patient’s Autonomy.
Supporting and enhancing an interactive dentist-patient relationship when an unchosen bad outcome occurs is now an ethical requirement for the second dentist as much as it is for the first. This is because the second dentist must now deal directly with the patient though the occurrence of a bad outcome does not automatically terminate the patient’s relationship with the first dentist. The second dentist’s first effort, for the reasons given, should be to maintain and strengthen the patient’s relationship with the first dentist unless doing so seriously conflicts with achieving these benefits for the patient. To determine if this is the case, the second dentist must decide early on, as clearly as he or she can, whether the bad outcome is the result of the first dentist’s bad work and then, if it is, determine how serious the bad work is. The dentist’s obligation to consider these difficult questions requires careful examination.
Some dentists will immediately say, “You never know for sure. You never have all the facts.” They conclude, therefore, that the second dentist is never able to legitimately judge that the first dentist did bad work.
Absolute certainty about the cause of an event is rarer than most of us think, even for an eyewitness. This is especially so when time has passed and one of the crucial players is not available. Still, many situations in life provide enough evidence about the cause of an event—even at a distance and with some points of view missing—that warrants a reasonable person to make judgments about the matter based on the evidence available. Other explanations of what happened are always possible, but sometimes the evidence available is strong enough to make those other explanations too unlikely. When this is the case, a reasonable person will have enough evidence to conclude that an error in judgment, technique, or communication on the part of another person has taken place. Therefore, while there are good reasons, as will be explained, for the second dentist to give the first dentist some benefit of the doubt, it would be intellectually dishonest to hold that the evidence of bad work is never sufficient. In sum, while we may never know all the facts, sometimes we know enough of them to know that we must judge that a bad outcome is the result of another dentist’s bad work.
It is unfortunate that the two phrases “bad outcome” and “bad work” sound so much alike. The word “bad” in the first phrase refers to the well-being of the patient. A bad outcome is an outcome that fails to accomplish some benefit of treatment for the patient or possibly involves some harm or risk of harm to the patient’s Oral or General Health. The same word, “bad,” in the second phrase refers to the minimum norms of dental care. Bad work is a diagnosis, treatment, or communication with the patient that fails to meet the norms developed and practiced within the dental profession.
This means that not all bad outcomes are bad work, because two different standards of judgment are involved. Unfortunately, in contemporary society—and in many dentists’ conversations with patients—the distinction between these two ideas is often overlooked. Rather than educating patients about the difference, most dentists—like most people in our society and like most patients themselves—prefer to say very little to their patients about the possibility of bad outcomes. The conflation of these two ideas is a serious malady of contemporary culture. A widely accepted myth of contemporary society holds that the technologies, techniques, and support systems for them within contemporary health care are as infallible as the science that developed them is imagined to be. It is part of this myth to ignore the fact that all our technologies, techniques, and support systems, and even “infallible” science itself, are the work of fallible scientists and other fallible human beings rather than coming from some truly infallible source.
The myth of infallible science has enhanced the status of physicians and dentists who employ these techniques and technologies to address patients’ ills. It has also shaped patients’ expectations to the point that many of them accept the dubious corollary of this myth—namely, that all bad outcomes must be the product of human error (that is, that they must be bad work). As a result, for example, much in malpractice law and insurance liability products is a response to this myth. Physicians, dentists, and professional organizations who use this myth to promote or defend their practices and professions, then, contribute to this cultural malady and its consequences. In such an environment, it is not surprising that dentists don’t talk to their patients very much about bad outcomes.
Every dentist knows, though, that even the most expert dentist practicing most carefully on a “textbook” mouth of a fully cooperative patient can still have a bad outcome. The myth of infallible science and its corollary of treating all shortfalls as instances of human error are false. A bad outcome is not necessarily a sign of bad work.
To judge whether a particular bad outcome is an instance of bad work, the second dentist needs information. In some instances, the bad outcome involves dental work that is physically defective, like the nonretentive preparations, poor marginal fit, and overcon-touring of the bridge in the case at the beginning of this chapter. But often the second dentist will have to make a judgment on the basis of physical evidence that is less clear. When a patient presents with significant periodontal disease, for example, the patient may state that the first dentist never informed him or her of either the first incipient signs or the continuing progression of any kind of periodontal involvement. This may be a defect in the patient’s memory, in the patient’s attention to the dentist’s words, in the patient’s comprehension of those words, and so on. In addition, some bad outcomes occur without anyone being at fault, simply because human knowledge and human technology is limited in the face of complicated natural processes.
The second dentist cannot justifiably conclude that a bad outcome probably is, or is not, the result of bad work without carefully considering the clinical facts, the patient’s comments about the situation, any available evidence that the patient has received, and whether the patient has understood the first dentist’s comments correctly. Even then, however, the most a second dentist will ordinarily be able to conclude—without obtaining information from the first dentist about the clinical circumstances in which he or she operated—is that the bad outcome probably is, or probably is not, an instance of bad work. The separate question—whether the second dentist may, or ought to, communicate such a judgment to the patient—will be examined shortly.
Most dentists ordinarily give another dentist the benefit of the doubt, even when there is considerable evidence that a bad outcome is the result of bad work. This may appear to be mere professional face-saving or an example of inappropriate loyalty. Giving the benefit of the doubt may appear, in such a matter, contrary to the obligation of the dental profession to the larger community—that is, the obligation to watch for and eliminate avoidable bad work as much as possible.
There are two good reasons for presuming, however, that another dentist has attempted to do good work in spite of a bad outcome. First, most bad outcomes have many possible explanations that do not involve errors by the first dentist. If there is no strong evidence of bad work in the clinical facts and the patient’s reports, it is more likely than not that bad work was not involved. Second, the technical education provided in accredited dental schools is carefully monitored, as is that of many of the dental profession’s continuing education programs. This is to assure the larger community that, when new dentists are licensed, they have the knowledge and skills they need to practice capably. Their continual practice, furthermore, ordinarily enhances dental expertise rather than weakens it, and the same is true in general about dentistry’s continuing education programs. All things being equal, then, it is most likely that a given dentist will conform to the relevant professional norms in any given clinical situation.
Situations will arise, nevertheless, in which the second dentist must conclude that a bad outcome probably is the result of the first dentist’s errors in judgment, technique, or communication with the patient. Other situations will arise where evidence is not conclusive but is still strong enough to outweigh the benefit of the doubt favoring the first dentist. In such a case, a dentist would have to conclude that bad work might be involved, even though the evidence does not resolve the question either way.
There are, then, three ethically distinct situations of potential bad work that a second dentist might face. Situations where (1) the second dentist judges that bad work is probably not involved, (2) the available evidence in the clinical facts and patient’s reports cannot resolve a question of bad work, and (3) the second dentist judges, on the basis of available evidence, that bad work probably is involved.
The dentist is clearly obligated, in all of these situations, as 4.C of the ADA Code puts it, to inform the patient of his or her “present oral health status.” This obligation derives from the Central Practice Values of Oral and General Health and also from the value of Autonomy. It is also required by the ideal of an Interactive Relationship between the dentist (either dentist) and the patient. All of these professional standards require that a capable patient receive sufficient, accurate information about his or her oral condition so the patient can make appropriate—and, it is hoped, interactive—decisions about it. (This chapter will limit its discussion to patients who are capable of participating in treatment decisions. See chapter 7 for the discussion of how to provide dental care for those not capable of participating or who have only diminished capacity to participate in the decision-making process. Obviously, bad outcomes and potential instances of bad work are likely to raise even more complex ethical questions when experienced in the care of these patients than they do for capable patients.)
Describing a patient’s “present oral health status” necessarily includes describing the facts of the bad outcome; the dentist’s professional obligations clearly require this of the second dentist. Additionally, there are no reasons to possibly override this requirement based in the dentist’s professional commitments. The second dentist does have obligations to the first dentist as a co-professional. Yet, even if these include an obligation to protect the co-professional from certain kinds of harm, the values at stake for the patient in this situation—especially that the patient understand his or her present oral health status—take priority over those at stake for the co-professional.
Might the second dentist support the first dentist’s relationship with the patient most effectively, perhaps, by not mentioning the bad outcome to the patient at all? If the patient is not aware of the problem or if the patient is led to believe that it is less important to oral health and function than it is, then the first dentist might deal more effectively with the bad outcome within his or her own relationship to the patient. Would this be a legitimate way, and sometimes the best way, for the second dentist to support the patient’s relationship with the first dentist?
Here the ethical complexity of the second dentist’s situation becomes clear. The second dentist is not simply the agent of the first dentist; the second dentist has a professional relationship with the patient as well. That is, the dental profession’s requirement to respect the patient’s Autonomy applies to the second dentist, as does the obligation to work for as interactive a relationship as possible with the patient regarding any matters the second dentist and patient must decide together. The second dentist should not violate the patient’s Autonomy or accept an alternate kind of relationship with the patient, then, for the sake of not weakening the first dentist’s relationship with that patient. This is another way that the norm of the Relative Priority of the Patient’s Well-Being is relevant. The patient’s Autonomy and the present dentist’s relationship to the patient take precedence over the first dentist’s relationship when these come into conflict even though the second dentist remains obligated to support the first dentist’s relationship with the patient in every way when no such conflict occurs.
In a former era in which the Guild Model of dentist-patient relationships seems to have had much more normative force in US society, it might have been considered professionally appropriate to refrain from fully informing a patient about a bad outcome so the first dentist could let the patient know in the context of his or her own dentist-patient relationship. As already stressed at several points, though, there is no question that the understanding of dental professionals’ obligations—in today’s ongoing dialogue between the dental community and the community at large—is that the Central Practice Value of the patient’s Autonomy and working for an Interactive Relationship with the patient take precedence over all other competing considerations, except direct risk to the patient’s Oral and General Health.
Therefore, in all three of the situations under consideration here the dentist is obligated to inform the patient about the condition of his or her mouth, including giving an accurate description of the facts of the bad outcome. However, this conclusion does not imply anything about what more the second dentist may or may not say, or ought or ought not to say—either to the patient or to a relevant peer review authority—about the role of the first dentist in regard to the bad outcome.
Regarding what the dentist might say to the patient, there are two different sets of circumstances that need to be distinguished. First, the patient may ask the second dentist whether the bad outcome is the result of the first dentist’s bad work. Under what conditions is the second dentist professionally obligated to respond to this question by saying that the bad outcome probably is the result of the first dentist’s bad work? Are there any other circumstances in which the second dentist may ethically say this, even if he or she is not professionally obligated to do so?
Second, even though provided with accurate information about the condition of his or her mouth, the patient still might not ask about the role of the first dentist. Are there any circumstances in which the second dentist is, nevertheless, required to broach the subject and offer a judgment about the first dentist’s role? Are there any other circumstances in which the second dentist may do so even if it is not professionally required? This last pair of questions will be examined below in the section titled “When the Patient Doesn’t Ask.”
If the patient directly asks the second dentist for his or her judgment about the first dentist’s role regarding the bad outcome, how ought the second dentist deal with this question? We begin with the third of the three kinds of situations distinguished above because it is the most complex.
If the Patient Asks When Bad Work Seems Probable
The third situation is the one where the second dentist judges—on the basis of the clinical evidence and the patient’s reports—that bad work probably is involved. It will shortly prove necessary to make two further distinctions about this situation that will divide it into four subcategories. We should first examine the strongest reasons for holding that the dentist in this situation should, however, always answer the patient’s question truthfully and accurately according to his or her best judgment.
First, as has already been noted, the Central Practice Values of the Patient’s General and Oral Health and the patient’s Autonomy as well as the obligation to work for as interactive a relationship with the patient as possible all argue for the dentist to fully inform the patient of the facts the patient needs for treatment decisions. The second dentist’s judgment regarding the first dentist’s responsibility in relation to the bad outcome would seem to be one of these facts, so an honest statement by the second dentist about the responsibility of the first dentist would seem to be required.
Second, every dentist has an obligation to carry out the dental profession’s commitments to the larger community. This means that the actions of individual dentists—though regulated and supervised only by other members of the profession—should nevertheless serve patients’ well-being both technically and ethically. A dentist who refrains from accurately answering patients’ questions about a first dentist’s role in a bad outcome—when that bad outcome is judged to probably be an instance of bad work—seems, then, to fail in this obligation both personally and in the name of the whole profession. Thus, in some measure, the profession’s privilege of self-regulation is placed at risk.
Third, the norm of Integrity and Professionalism requires that dentists’ actions be guided by the values that the profession professes to uphold. As an expert group, the dental profession professes that its members always act in accord with clinical facts and place the well-being of patients ahead of their own (though within certain limits, as noted previously). A dentist who does not accurately answer patients’ questions about the causes of a bad outcome—when these are judged to be probable instances of bad work—misrepresents the profession by, first, setting aside fact and, second, placing a co-professional’s well-being above a patient’s, thus misrepresenting the values for which the dental profession stands.
However, these normative considerations apply to different subcategories within this third situation in different ways, which leads, then, to different ethical conclusions about them rather than to the generic conclusions that may have appeared to follow from them so far. The first distinction that needs to be made is between, on one hand, instances of bad work that involve significant potential for future bad work (and possibly worse harm to the patient) by the first dentist and, on the other hand, instances of bad work that are merely the minor and/or occasional errors that inevitably occur in all expert practice simply because humans are fallible beings.
The ADA Code identifies a relevant distinction in section 4.C, where it says the dentist must determine whether the first dentist’s bad work is an instance of “gross or continual faulty treatment.” The authors interpret this to imply that some bad outcomes are only instances of the occasional and isolated technical errors that even the best of professionals inevitably make now and then. Obviously, concluding that a bad outcome is an instance of continual faulty work requires evidence from other occasions and almost always from other patients of the same dentist. The judgment that an instance of faulty treatment is gross does not require such a body of comparative evidence; it is less difficult to make the judgment of gross faulty treatment in practice, then, than the judgment of continual faulty treatment. The judgment that a bad outcome is probably the result of gross faulty treatment is the judgment that the error is so serious or harmful that it must be considered potentially symptomatic of a serious lack of caution or of proper training or of some other problem that the first dentist is not addressing. In both instances, since the second dentist is judging the bad work as gross or continual faulty treatment, the second dentist is also judging that the patient is at some risk of further bad work, and possibly longer-term harm, if he or she returns to the first dentist.
The dentist who never makes an error in clinical judgment, especially on a close call, and who shapes every restoration, makes every preparation, and takes every impression utterly flawlessly, leaving every patient happy and fully satisfied, is extremely rare, if such a practitioner can be found at all. Most such shortcomings from the theoretical ideal of perfect technical practice do not, though, cause discomfort or harm to patients, or they are brought back to the same dentist who was responsible for them for adjustment or redoing. Thus, when they occur, they are mostly resolved within a single dentist-patient relationship, without the involvement of a second dentist.