Rosa is a radiant, affectionate 10-year-old girl who was adopted from Central America. The restorative dentistry that had been provided for her before her adoption was accomplished without local anesthesia. Although she makes every attempt to cope with your recall visits during your surveillance of her growth and development, even gentle examinations cause her significant anxiety. Fortunately, her caries experience has dwindled because of her improved oral hygiene and fluoride applications since her adoption. But this afternoon’s evaluation shows that a serial extraction sequence involving the removal of 4 first premolars appears to be required to correct her severe crowding. You sense that disclosing this to Rosa’s mother in front of Rosa would upset Rosa immensely.
You advise the family that Rosa is ready for records production and diagnosis. Rosa’s mother acknowledges that the family is aware of the severe crowding. She then asks, “But where will you get enough room for all those teeth?” A heavy silence pervades the room as Rosa looks up at you with her big brown eyes. You can hear a pin drop, and you know that your next words must be carefully chosen if you are to keep the atmosphere in balance. Are you obligated to disclose your clinical diagnosis and probable recommendation to Rosa, or is it sufficient to communicate solely with her mother?
There is scant literature about the level of veracity that a preadolescent should receive about her medico-dental status or prognosis, but this is an important issue for those of us who treat young patients because of our dependence on their cooperation in therapy. Publications regarding the importance of providing disclosure to juveniles who have been diagnosed with human immunodeficiency virus (HIV) may hold some pertinence, even for clinicians who treat patients with less severe afflictions. Until the 1970s, patients of all ages frequently received little or no information about the prognoses of their diseases for a variety of reasons. Not only was disclosure of bad news stressful and time-consuming for the provider, but clinicians feared that a patient could lose the will to improve or even adopt a self-fulfilling prophesy of decline if told that the prognosis was poor. That same epoch saw an improvement in survival frequency and evidence of sufficient cognitive behavior in children to accept and adapt to illness. Most importantly, clinicians began to recognize the need for a child’s trust and cooperation in promoting favorable outcomes in recovery. Disclosure of the truth was seen as upholding the ethical principle of veracity.
Yet the absence of disclosure is not the equivalent of a lie and sometimes might be warranted. For example, is it necessary to tell your son of his recurrent stutter before it is diagnosed at school or before his peers draw attention to the problem? Would you point out a friend’s physical fault to her if there is no merit in doing so?
Some ethicists have suggested that appropriate disclosure involves revelation of the facts that a reasonable person would want to know. This can be an ambiguous guideline but does offer some perspective on how much disclosure is appropriate. In the doctor-patient relationship, there is an implied promise that the doctor and the patient will share the burden of truthful disclosure equally. This begins with the patient’s first phone call to the office and includes honesty in communicating demographic information, health history, and previous treatment experience.
How much will you tell Rosa about the necessity of her extractions? How do you decide which truths this youngster can tolerate? Although your approach to this dilemma will vary among patients based on a plethora of reasons, at least some intimation of the need for her complex treatment involving the extractions should be broached. After all, your relationship with her is just beginning—and her enduring trust in you will be indispensable to the quality of her treatment.