“Still, a man hears what he wants to hear, And disregards the rest”

It’s been 2 years since you finished your residency, but you feel as if you received your certificate just last month. In addition to all the education loans you have accrued, the mortgage payment for your modest condominium is now due. You’ve also become increasingly focused on your biologic clock, and you and your husband have repeatedly discussed your mutual desire to become parents soon. There’s no possibility of purchasing a practice until your loans are repaid, but you cannot deny the pressure you feel to meet all of these financial demands. Your present remuneration schedule as an associate orthodontist is based on your production level, so the more patient starts you can generate, the better. But the treatment priorities of many of the patients you see for initial examinations are not well defined. Several patients with early transitional dentition might benefit from mere watchful growth and development. An adult with active periodontal disease was told elsewhere that she could begin treatment immediately, but you are not so sure that orthodontic correction should take priority over initial periodontal therapy. And a middle-aged woman with over two thirds root resorption of her maxillary incisors will need surgical correction or extractions to address her chief complaint of protrusion. Should you suggest that she proceed regardless of her high-risk status? As you consider the dilemma of whether to start treatment on each or any of these patients, you get a mental image of a spreadsheet that delineates all of your expanding debt.

A frequent but unrelenting question from the day you begin your practice until the day you retire is whether to recommend treatment. Orthodontic correction is usually elective, but our decision of whether to recommend treatment should never be influenced by our need or desire for financial gain.

Motivational blindness is a bias in which people overlook contradictory information when deciding whether to proceed with further action. This can occur when ethical, honest people become confused or diverted by a conflict of interest. For example, in the 1990s, Sears, Roebuck and Company assigned a production rate of $147 per hour to their mechanics in an effort to increase the mechanics’ work speed. But instead of working more quickly, the mechanics performed more repairs than necessary or overcharged to meet the requirement.

Studies have confirmed that once a person commits the first ethical transgression, subsequent lapses in ethical behavior occur more frequently and with less inhibition. This is called the “slippery slope” phenomenon as minor ethical transgressions become more serious. As time passes, any previous inhibition toward unethical action dwindles considerably.

In orthodontics, the slippery slope, fueled by motivational blindness, can become just as pervasive. Overtreatment or fee inflation might be perceived to be justified by some doctors who feel entitled because of the professional debt they have accumulated. No level of debt warrants indiscriminant treatment of any patient. We must not be blinded by the biases of our own predicament. And we don’t need to be. Trustworthy business relationships have repeatedly been documented to lead to stronger revenues and less staff turnover than in those in which low integrity predominates.

Most ethical transgressions are made by the best among us: well-meaning, honest people who, in a moment of weakness, become temporarily nearsighted. We don’t want to be the man or woman who sees what he or she wants to—and disregards the rest. It’s up to us to keep our lenses from fogging so that we will never be blinded.