Ten-year-old Jimmy Campli is in your office for another surveillance appointment to evaluate his dentitional development. Jimmy’s deciduous teeth have been slow to emerge, and development of his permanent dentition is likewise delayed. The mandibular deciduous canines are beginning to mobilize. This finding, in conjunction with a recent panoramic radiograph, leads you to conclude that only routine dental maintenance is needed. Mrs Campli advises you that Jimmy has an appointment with a new dentist next week. You ask her to have the dentist keep you apprised of any significant developments and assure her that you will collaborate as Jimmy matures.

About a week later, you receive a call from Mrs Campli. She tells you that the dentist has scheduled Jimmy the next morning for extraction of all 12 of his remaining deciduous teeth, using local anesthesia. She says the dentist was emphatic that the extractions must be accomplished immediately to correct Jimmy’s delayed eruption. She is concerned that the fee for the extractions will severely burden the family’s finances, since her husband has been unemployed for about 6 weeks. You fumble for Jimmy’s panoramic film to confirm that the root development of the succedaneous teeth is insufficient to warrant this procedure. Mrs Campli also fears that Jimmy cannot tolerate the extractions, because he had a traumatic experience when 2 deciduous incisors were extracted. And in your estimation, extraction of the deciduous teeth would necessitate bimaxillary space maintenance—another service that the Camplis cannot afford!

“Faced with what is right, to leave it undone, shows a lack of courage.”

Courage. A virtue that has been valued for centuries. Courage has been the subject of writers and thinkers throughout history from Aristotle and Plato, to Steve Jobs and Nelson Mandela. Courage exists in many forms. As orthodontists, we often need moral courage in relationships with colleagues and patients. This form of courage might defy the risks of isolation, retaliation, or ridicule to remain protective of values we know are right. When it comes to patient care, moral courage involves prioritizing a patient’s best interests above that of the provider, even if doing so invokes embarrassment or shame—or risks future referrals.

Moral courage must be differentiated from moral arrogance and moral certitude. Moral arrogance is the stance that one’s opinion is the only correct opinion, although other morally acceptable options exist. A morally arrogant orthodontist might say, “I’ll persuade my patients to accept the treatment plan that is best for them. I’m the doctor, and I know what’s best.” However, another orthodontist might defer the choice of the treatment plan to the patient, without any prompting whatsoever. Moral certitude is one’s assertion that a stance is correct irrespective of its validity. For example, the doctor might say, “I would never apologize for any clinical mistake I have made. Apologies are an admission of error, and that leaves me liable.” Yet, there are ample data to substantiate that apologies can often avert future problems.

Moral courage differs from both moral arrogance and moral certitude in that moral courage involves protection of a moral principle that is at risk of violation.

The salient question is whether moral courage can be taught. Scholars dating back to Aristotle agree that moral courage can be at least enhanced. Respect for moral courage is demonstrated as early as preschool through classical stories and fables, and extends into adulthood via character portrayal in all genres of entertainment, including operas, plays, movies, and literature. The message is recurrent: one must have the courage to do what is right, regardless of the consequences. Moral courage is inspired by personal exemplars of courage as well as case scenarios.

Time is running out for young Jimmy and the Camplis. You know the extractions are unnecessary. You must have the moral courage to communicate that to the dentist in a collegial way. Despite the dentist’s loss of clinical time and income that will result from cancellation of the procedure, the patient is your primary concern. Your action might even threaten a potential referral source. But your main priority is your patient.

That’s moral courage.