Karen is an anesthesiology resident and your last patient of the week. Her chief concern is the irregularity of her maxillary incisors. She describes her experience of prolonged, comprehensive orthodontic therapy as an adolescent. She says that she had “4 years of treatment with 8 teeth extracted and a night brace—the works!” She admits that the result was never ideal, even immediately after treatment.
Her history does not surprise you. Her excessive facial convexity and vertical maxillary excess, including abundant gingival display and long lower facial height, are evident the moment you meet her. A 5-mm anterior open bite with maxillary constriction is obvious. You complete your examination and suggest bimaxillary surgery as the ideal way to address the problem, including segmental LeFort and mandibular advancement procedures. As you begin to advise Karen that assessment of diagnostic records is needed to verify your initial impression, she stares back at you defiantly and exclaims “No way!” She says that she sees many of those surgeries in the operating room and “no surgeon will do that to me!” She also politely declines fixed therapy but asserts that she will be highly compliant with esthetic aligners. You patiently explain the shortcomings of such correction, but she says that she doesn’t care. “No braces and no surgery,” she retorts.
We are well aware that informed consent is essential to orthodontic treatment delivery. Informed consent is a hallmark of the ethical principle of autonomy, as we give our patients sufficient information for them to choose a treatment plan. Our intent is to disclose the risks and benefits of treatment, as well as available options, to address each patient’s concerns. Also included should be the consequences of foregoing treatment altogether. In providing autonomy, an orthodontist should strive to bridge the gap between the professional’s perspective of the problem and the patient’s objectives of treatment by building a consensus between them. Contrast autonomy with the principle of paternalism in which the practitioner decides what is best for a patient, irrespective of the patient’s input.
Despite our efforts to emphasize the value of an ideal treatment plan, some patients choose a plan that is less than ideal—possibly one that might be prone to instability or could fail to address functional deficiencies. If we agree to treat that patient, and the patient accepts the shortcomings of his or her treatment choice, we are treating under informed refusal.
Informed refusal can occur for various reasons. Previous experiences, prejudices, religious beliefs, cultural lore, financial limitations, phobias, or simply a whim might be sufficient grounds for a patient to reject the ideal option and choose a significantly compromised alternative. An orthodontist must be introspective to be certain that the risks, benefits, and options were explained clearly and thoroughly in nonprejudicial, lay terms. Time for free dialog between the practitioner and the patient must be allowed to explore the patient’s questions and concerns. A practitioner should never view a patient’s rejection of an ideal treatment plan as a personal affront. And a practitioner has full autonomy to refuse to provide therapy if the limitations imposed by the patient jeopardize his or her dental health.
The most difficult aspect of providing informed consent can be the determination of the degree of detail disclosed for each treatment option. Although one should be as thorough as possible, excessive details or many treatment choices can create confusion—perhaps even bewilderment—resulting in the patient’s ambivalence toward treatment.
What do you say to Karen if she severely limits your treatment options? The ultimate responsibility of obtaining informed consent or accepting informed refusal is the orthodontist’s obligation. If informed refusal is the patient’s choice, the next choice is yours.
The author acknowledges the great influence of the book Dental Ethics in the development of this editorial.