Melanie is a friendly second-year architecture student with a pleasant smile. You notice her right maxillary midline deviation the moment she greets you. Her chief concern is “My smile looks lopsided.” She had recently lost her maxillary left premolar from a vertical fracture. Her mandibular arch is fairly well aligned, and her periodontal charting and radiographs confirm that she is periodontally resistant. You produce diagnostic records and a diagnostic wax setup, both of which indicate that closure of the maxillary left premolar space is her ideal treatment plan. She will be leaving your town in precisely 11 months when she graduates. Her face lights up when she tells you that she will then be married and accept a position in her father’s firm. She is extremely motivated to proceed with treatment under 1 condition: that you complete it by her graduation.
You’ve remained current in your continuing education requirements and just last week completed a course in accelerated tooth movement. You’ve always wondered whether a career in oral surgery might have been as gratifying to you as has been your orthodontic career. After all, you place your own temporary anchorage devices, perform your own fiberotomies, and extract deciduous teeth with confidence and ease. The lateral corticotomy and associated bone grafting procedures seem straight-forward and logical—especially if the procedure is necessary in only the maxillary left quadrant. Your subsequent review of the limited specialists in your area fails to identify any who are experienced in the corticotomy procedure. You begin to ask yourself whether you can perform it yourself.
You explain to Melanie at her treatment consultation that such a procedure has been shown to greatly decrease treatment time and should permit treatment completion in less than a year. You add that the results you have seen have been impressive. You do not mention that your sole exposure to the procedure has been through journal reviews and presentations given by experienced clinicians. Melanie is enthused to proceed with both the full correction and the corticotomy. Her trust astounds you. “My dad told me he’s ready and able to pay your total fee in advance,” she exclaims. “We’re so excited that you can complete my treatment by my wedding!”
Nonmaleficence is an ethical principle that has endured for centuries. Stated in Latin as “primum non nocere,” nonmaleficence is interpreted as “first of all, do no harm.” Harm can be physical or emotional and can include deliberate endeavors as well as inadvertent acts such as negligence. Consider the simple act of placing separators before banding in which injury to soft tissues, impact on periodontal status, and moderate pain are realistic possibilities. Fortunately, in most accepted procedures, beneficence (doing good) outweighs maleficence. Thus, the comparatively minimal harm or discomfort to the patient warrants the greater benefit of healing or correction.
Nonmaleficence might be a relative consideration. Some forms of chemotherapy to treat malignant neoplasms involve benefit-to-harm ratios at an entirely different level. The “consequence maximizing principle” is a quasi-arithmetic subtraction of potential good minus potential harm in which the benefit should exceed the (minimal) harm incurred by any procedure. Chambers further defined nonmaleficence as becoming fully knowledgeable of the science of a procedure with a competence level equal to that of one’s colleagues. Providing patients with the autonomy to comprehend a level of risk they can accept is also required.
Now back to your ethical dilemma. You have a vulnerable patient in Melanie, unaware of your minimal levels of expertise and experience in lateral corticotomy procedures. Will you permit her to accept the associated risks in an invasive procedure you have never attempted? She is eager to complete her therapy quickly, and certainly willing and able to pay the price from a financial perspective. Now the question is whether you are willing to pay the price from an ethical perspective. It might be most appropriate for you to suggest that she start her orthodontic treatment when she returns from her honeymoon.