Your last patient of the week is Teddy Rector, a quiet 12-year-old who is brought to you by his mother for an initial evaluation. Ms Rector communicates her dissatisfaction with Teddy’s convex profile, which is secondary to an obvious bialveolar protrusion. “The kids call him Horseface,” Ms Rector says. After your clinical evaluation, you advise that extraction of 4 first premolars is the ideal strategy to address the chief complaint. Ms Rector nods and says that this confirms a previous recommendation Teddy had received. Although she and Teddy are well motivated for treatment, Ms Rector explains that she is divorced from Teddy’s father and shares joint custody with him. The father is adamantly opposed to the extraction of any permanent teeth—or any form of orthodontic therapy—based solely on his assertion that he “likes Teddy’s teeth the way they are.” Communication with Teddy’s father has been contentious. At Ms Rector’s request, your staff schedules Teddy for production of diagnostic records and a consultation appointment next week.

Teddy is not the first child of divorced parents whom you have treated. You are eager to help this young man, but you do not want to place yourself in a position of vulnerability with either of Teddy’s parents. How should you proceed?

Treating children of divorced parents involves both ethical and legal concerns, and the demarcation between ethical and legal issues can be vague. The ethical aspect involves the clinician’s respect for the family’s autonomy. The legal aspects, including the age of majority, are subject to state laws. Joint legal custody is court-supported documentation allowing each parent the autonomy to make decisions on behalf of the child. Contrast legal custody with physical custody, in which the child resides with 1 parent, yet that parent might not have the authority to make decisions regarding the child’s care. Unauthorized treatment in a joint custody situation can initiate parental mistrust in the orthodontist. Unilateral approval for treatment could also lead to a complaint to an attorney or the state dental board. In some jurisdictions, violation of a joint custody agreement could result in civil or criminal charges against the orthodontist. Exceptions to seeking joint consent might include an inaccessible, abusive, or neglectful parent. If the practitioner is in doubt about the nature of the custody, he or she should request a copy of the custody agreement or a letter from the family attorney to verify that the custody agreement does not preclude treatment of the child.

Both parents should sign the child’s financial contract to share the financial responsibility. Alternatively, 1 parent can be responsible for the contract, rather than sharing it between the 2 divorced parents. It is likewise best to discuss the treatment options and the risks of treatment with both parents to be certain that your obligation to provide full autonomy is fulfilled.

Every effort should be made to avoid acting as an intermediary or a puppet between the parents. I recall a treatment-planning consultation I had with a newly divorced, especially truculent mother and father. Although I attempted to meet each parent separately, the parents’ scheduling restrictions precluded this luxury. The mother insisted that I sit between her and the father, and refused to address the father directly in any way. She repeatedly asked him questions by relaying them through me, although we were all sitting at the same table. His replies were understandably laconic with an authentic tone of hostility. Quite an uncomfortable arena for us all!

Both parents should be constantly informed of treatment progress and cooperation levels throughout treatment—even if it is not required by the custody order. Communication is mandatory to remain aloof from any domestic conflict.

In all cases, including Teddy’s, we merely make treatment recommendations, but the family makes the final treatment decision. That’s true autonomy.