Your abbreviated orthodontic therapy for Ms Bell is about to conclude. The referring dentist requested that you upright the mandibular left second molar a few more degrees before implant replacement of the absent first molar. The gable bends you placed at last month’s appointment induced occlusal trauma with the maxillary arch, so you begin to reduce the relatively new ceramic crown on the mandibular second molar. Suddenly, you notice that you’ve perforated the second molar crown. Ms Bell has no idea of the problem as she continues to listen to the music from her iPod. You wish you had mentioned this possibility before your adjustment, but in your haste to stay on schedule, you hadn’t.
Now your conscience kicks in. You wonder whether you should tell Ms Bell about the perforation. On one hand, she doesn’t know it occurred, but on the other, how would you feel if future leakage caused decay to the tooth? This would necessitate further treatment or, worse yet, potential extraction.
One of the most important ethical principles we face each day is that of reparation. Much of what we do for patients occurs in the restriction of the oral cavity—a region where patients know little of our failures unless they feel pain or perceive dysfunction. When we injure a patient, even without the patient’s knowledge, our ethical duty is to provide reparation. Defined in the ethical sense, reparation is the duty to make amends for injury or damage we have caused.
The philosopher W. D. Ross (1877-1971) proposed his concept of “prima facie” duties, which are ethical obligations indicated at “first glance”: those duties that we are bound to provide unless they are overridden by other ethical responsibilities. A prima facie duty carries a strong indication for completing the obvious ethical requirement. Reparation is a common-sense action, unless providing it is contradicted by another prima facie ethical principle. Consider a possible scenario in orthodontic practice: you discover that your failure to recover a gingivally displaced separator creates a significant periodontal abscess. Your patient is in pain, with regional lymph node adenopathy and low-grade fever. Your contemplated reparation would be to retrieve the separator as a prima facie duty. However, if your patient requires antibiotic prophylaxis before initiating a procedure that induces gingival bleeding, you might delay entering the area in respect of the ethical principle of nonmaleficence (do no harm). You would postpone retrieval of the separator until the patient is adequately premedicated.
One advantage we have as orthodontists is that reparation can often be readily provided. Given the number of patients we see each day and the high level of delegation inherent in an orthodontic practice, errors can and do occur. Despite such delegation, we are responsible for not only our own but also our staff’s actions in care delivery. If clinical misadventures do occur, it is incumbent upon us to provide reparation before it is solicited by the patient. The patient must be promptly and accurately informed of the misadventure. Remediation of the problem should be arranged without expense to the patient. Although the purpose of professional liability insurance is to provide the patient financial reparation in the event of a therapeutic misadventure, a patient’s trust in us can be lost forever if we are not voluntarily forthright when reparation is indicated.
In the case of Ms Bell’s perforated crown, you should explain the complication and offer to arrange for replacement of the restoration. The cost of the restoration is your responsibility.
Remember, always do the right thing—even when no one is looking.