Mr Walter Baron was a businessman in his early forties who lived in a small university town in the northeastern United States. His dentist referred him to Dr Allan Wagner, an oral surgeon, for the removal of a mandibular premolar.

The tooth was painful and had a history of unsuccessful treatments. Dr Wagner agreed that extraction was necessary. Before extracting the tooth, he asked Mr Baron what the subsequent treatment was going to be. Mr Baron replied that a three-unit fixed partial denture was planned. Dr Wagner saw that neither of the abutment teeth was compromised with caries or restorations. Because of these facts, it appeared to him that an implant would be a good alternative for Mr Baron.

Dr Wagner had placed many implants with good success, but he knew the referring dentist had never done implant therapy and in fact knew very little about it. Recommending an implant to Mr Baron almost certainly would irritate the referring dentist. Dr Wagner might also be accused of conflict of interest because he was the only local oral surgeon who performed implant therapy. Yet he thought that it would be a good treatment and seriously considered discussing the implant with Mr Baron.

DISCUSSION:

The key questions here are why the referring dentist recommended the three-unit fixed partial denture and why Dr Wagner prefers the implant. The referring dentist might believe that the fixed partial denture is the only option available, in which case there is a competency issue. On the other hand, he might realize that an implant is possible but wants to keep Mr Baron as his own patient to gain the income from providing the fixed partial denture. If that is the case, the issue is not competency, it is honesty.

Likewise, Dr Wagner might favor the implant because he really believes it is the best option, but he might merely want to perform the treatment to gain the income. If either dentist is pressing his choice to keep the patient for himself, it seems clear that self-interest has overpowered concern for patient welfare.

One option would be for Dr Wagner to present the options to Mr Baron and then to let him choose. That would seem to be consistent with the principle of autonomy and informed consent. What would be the advantages and disadvantages of this option? How should Dr Wagner’s behavior differ depending on whether he believes the referring dentist is simply lacking in knowledge or is purposely trying to hold on to the patient?

Billy Baum, age 12, was referred by his grandfather, a dentist, to Dr Gary Broyles, an orthodontist, for the management of a severe malocclusion. Dr Broyles’s examination showed the presence of significant protrusion and severe crowding. Although Dr Broyles usually did not like to extract teeth, the crowding was so severe that extractions were clearly indicated. He told Billy’s parents his opinion.

Billy’s grandfather was unhappy with Dr Broyles’s opinion and contacted a former orthodontic chairman at the nearby dental school. Now retired, the former chairman suggested that Billy be seen by his son, Dr John Caplan, who was also an orthodontist. Dr Caplan examined Billy, agreed with his father that extractions were not necessary, and accepted Billy as a patient.

Dr Broyles later saw Dr Caplan at a dental meeting and asked him how he could treat Billy without extractions. Dr Caplan responded, “Oh, I will extract the teeth all right—when I’m ready.” To Dr Broyles’s protests, Dr Caplan said, “You might feel that you are right, but I have the patient.”

Dr Broyles was upset, having previously thought of Dr Caplan as a friend.

Dr Philip Pressley is a general practitioner who is known as a family dentist. However, much of his practice involves orthodontics. His typical strategy for obtaining consent for orthodontic treatment (at least for patients with insurance) is to tell the parents that the child needs braces and that treatment should be started right away. He suggests that he could undertake preliminary treatment immediately—that day, if the parents so desire. They can discuss the details of the case and the fees later.

With even a tentative agreement from the parents, Dr Pressley takes preliminary measures such as making impressions or cementing brackets. If the parents refuse, he does not charge them for any appliances but he does bill the insurance company. If the parents agree, he proceeds with treatment and bills the insurance company. Then when the insurance benefits are depleted, he tells the parents that treatment is not working and refers the patient to an orthodontist, usually Dr Philip Leighton.

Dr Leighton is tired of protecting Dr Pressley and angry about his dishonesty, but he does not want to instigate trouble.

DISCUSSION:

The practices of the dentists in these two cases raise ethical and legal questions. Both seem to be engaging in dishonest or deceptive practices for the purposes of gaining new patients. They may believe that their behavior is legal even if it is not ethical. However, each dentist is clearly not providing all of the information that the reasonable patient would want to know prior to giving consent for treatment; they are treating without an adequate consent. Thus the practices seem unethical and illegal as well.

The real issue is not the assessment of Dr Caplan or Dr Pressley. These deceptions are severe enough that we can assume that they are at least unethical. The real issue is how the colleagues who become aware of these practices should respond. Dr Broyles and Dr Leighton could confront the offending dentists directly. They could report them to the local dental society or state licensing boards. There are also steps beyond this that could be taken, such as directly alerting patients and the local press. Should Dr Broyles and Dr Leighton pursue these options or work strictly within professional channels?