Your 12-year-old patient is the daughter of the senior partner in your town’s largest law firm and has returned from the oral surgeon after the extraction of 4 first premolars. Not a remarkable scenario, except that the mandibular right first premolar was mistakenly extracted instead of the prescribed, resorbed right second deciduous molar. To complicate matters, there is agenesis of the succedaneous premolar. As you feel your pulse rate increase, you realize that your communicative skills will be essential in managing of this issue.

Communication in the face of conflict is difficult for almost everyone. How would you address this situation?

Your first intention should be to maintain “veracity” (truth telling). In managing situations of potential conflict, the patients, the parents, and all providers involved need to know a straightforward, accurate, and bias-free account of what has occurred. This communication is the first step in reestablishing trust as well as defining the patient as a person rather than as a procedure or a subject. But what about the potential consequences of disclosure of an iatrogenic problem involving the child of a prominent attorney, as in this case?

The German philosopher Immanuel Kant (1724-1804) defined the ethical principle of the categorical imperative as “doing what is right for its own sake regardless of consequences such as rewards or punishments.” The Judeo-Christian duty to “do unto others as you would have them do unto you” is an extension of this categorical imperative, which also parallels the Confucian philosophy of “do not impose on others what you yourself do not desire.” Although medical ethicists will deliberate whether truth telling is universally applicable for patients with a hopeless prognosis, dentistry has few such situations. For that reason, the philosophical and religion-based guidelines in this paragraph should be universally applied, regardless of any repercussions.

In this case, the ensuing communication should include not only an account of what happened and its implications, but also a plan of reparation: a plan to remedy any harm that has occurred. When a conflict arises from a misadventure or misinterpretation, the providers have the duty to provide resolution of that problem. Although legal professionals might maintain that remediation could be interpreted as an admission of guilt, reparation is an authentic concept from an ethical perspective.

Since the harmed person in this scenario is your patient, you decide to take the leadership role in communication. The disclosure to the patient or parents should be conducted promptly and directly after discussion with the oral surgeon and your malpractice carrier. Communication with the malpractice carrier is essential because the insured could be denied coverage if the insured fails to notify the carrier as soon as a problem arises. Dental ethicist Anne Koerber, DDS, PhD, offers the following advice on difficult communication: “The best way of handling angry patients is to hear the patient out and reflect back to the patient’s understanding of why (he/she) is angry in a non-defensive manner. When the patient understands that the dentist has heard her, then the dentist can invite the patient to suggest a solution, and begin a negotiation process. Koerber further states (in the case of a discussion between 2 doctors): “the communication danger arises when one person is taking a stance of being morally superior to another person. By keeping the communication focused on facts, i.e. ‘my policies are . . .’ instead of ‘you shouldn’t be doing that,’ one-upmanship is avoided.”

In our case, the appropriate tact begins with a truthful disclosure that the wrong tooth was extracted, followed by an offer of possible solutions. Although you might be concerned about legal repercussions, your best course of action from an ethical standpoint involves disclosure of the total truth with a level of compassion that the patient and parents can appreciate—even those highly skilled in using the power of the law.