Sandy is a lovely 13-year-old patient and your daughter’s classmate. Your initial examination revealed a left Class II relationship with peg-shaped lateral incisors. The retained maxillary left deciduous canine lies mesial to the maxillary left permanent canine. The rest of the secondary dentition has erupted. The family is concerned about the disproportion of the maxillary anterior teeth as well as the maxillary right midline deviation created by the extra tooth structure.
You produce orthodontic records that confirm that you’ll need to extract the retained left deciduous canine for midline correction. Distribution of the maxillary lateral incisors in preparation for eventual augmentation will follow.
The panoramic film and your prescription are immediately sent to the general dentist, and you advise the family to make an appointment to bracket the maxillary arch once the extraction is accomplished. One week later, during a busy after-school rush hour, you receive a nonchalant phone call from the general dentist. He tells you that he had received the film and your prescription, but he “accidentally lifted out the permanent canine instead of the baby tooth.” When you ask him if he told Sandy’s mother about the error, he says he did not because he “knew you could still treat the case just fine anyway.” You hang up the phone, albeit a bit dazed, and get back to your bustling office.
Later that night after your last patient has left, you retrieve Sandy’s study casts. You consider substituting the maxillary left first premolar for the extracted canine but wonder how much you should tell the family. Do you treat the case to completion and “cover” the dentist for his error, or do you explain the misadventure before you initiate any further treatment?
One responsibility of membership in a health profession is the role of the fiduciary relationship. Based on the ethical principle of fidelity (keeping one’s commitment and promises), the fiduciary relationship implies that trust arises between the patient and the doctor as an integral part of the professional alliance. The patient’s “blind faith” in the skills and goodwill of the doctor, coupled with the doctor’s superior knowledge of his or her specialty, places the patient in a position of high vulnerability. The patient trusts that his or her interests and needs will surpass the doctor’s in treatment delivery.
Immanuel Kant (1724-1804) belonged to a group of philosophers called deontologists, who believe that fidelity is one’s moral duty regardless of the ultimate consequences of an action. Kant believed that duty—doing what is right for its own sake—is more important than the outcome of an endeavor. Contrast deontologists with utilitarians, who hold that the consequences of one’s actions are the basis for judging an action as right or wrong. If an action brings eventual good or happiness, a utilitarian would consider the action morally justified.
If Kant were alive today, he might say that the correct action is to report the error to Sandy’s parents even if there are negative repercussions from your disclosure. Kant would see that gesture as respect of fidelity. A utilitarian, on the other hand, might suggest that there is no moral reason to inform the family of the error if the final result is of equal quality, regardless of extraction of the wrong tooth.
Fidelity can be explicit, for example, when an orthodontist promises that he can align a relapsed maxillary central incisor with solely a removable appliance rather than fixed-appliance therapy. Fidelity can be implicit, when that same patient perceives that the fee to align that incisor will be customary and not excessive. Both explicit and implicit fidelities are equally binding. Fulfillment of both forms of fidelity, especially when unmonitored by others, is one of the most rewarding aspects of providing professional care.
If a therapeutic error could go unnoticed, is there application of the cliché “what she doesn’t know won’t hurt her?” After all, in Sandy’s case, you plan to resolve the mistake by mesialization of the first premolar to replace the extracted canine. Does she have the right to know what has happened to her body? Should her parents have the prerogative to change dentists if they knew about the misadventure? To deprive the family of this information can deprive them of autonomy. Then there is the concern of nonmaleficence. Is the chance of root resorption amplified by significant movement of the premolar? Does mesialization of a first premolar into the narrow alveolus of a canine site predispose the patient to future gingival recession? Finally, the principle of justice might also be brought into question in this case. Should the additional fees to modify the coronal form of the mesialized premolar or for a gingivectomy to harmonize soft-tissue height be absorbed by the patient’s parents? Is the patient entitled to be compensated for an error that might involve more treatment than would be necessary if the error had not occurred?
Your fiduciary responsibility as a professional seems to point toward informing Sandy and her parents of the misadventure. You know that the family’s trust in you is invaluable and needs to be protected. Discussion of the issue eliminates the possibility that a future provider’s inquiry about the missing canine will undermine the family’s confidence in you or her present dentist. But, on the other hand, if the ultimate result will be equivalent regardless of the extraction of the canine, does the family really need to know? Your reverence for the fiduciary relationship with this family might be the deciding factor.
The dentist’s genuine apology, in conjunction with your support, might assure the family that you will collaborate to do the best you can on Sandy’s behalf. It is the first step in a sincere effort toward reinforcing their trust in dentistry—and in you both.