Finally! Your residency has concluded, and you can begin your long-awaited career. Ever since your uncle treated you as an adolescent, the thrill of that “wow moment” on the day you were debanded has remained vivid in your mind. As the junior associate in an established practice, at last you can provide that same thrill for someone else. You can’t wait to get started.
The structure of the practice you have joined calls for you to place the appliances after your senior associate has developed a treatment plan. Although you were unaware of this arrangement until you began work at that office, the concept seemed acceptable when it was first revealed to you. But before long, you find yourself in a precarious situation. Many of the treatment plans that are dictated to you seem to violate the fundamentals you learned in your residency. For example, patients are diagnosed solely from photographs and without digital or traditional study casts or films. In fact, diagnostic records are not produced at all. And a periodontally involved adult was fully bracketed on the day of her initial examination “to economize office time,” as per the assignment of your senior partner. When you question whether that patient had received periodontal clearance, your senior associate barks, “Just get the patient started, and we’ll worry about that next visit!” Hmm, you think to yourself: “This doesn’t add up, especially when I recall what I learned in my residency.”
You decide to arrange for a lunch meeting with your associate to discuss the matter. After the usual polite chatter, you directly express your concern about her insistence that you must treat these patients her way. But you sense that your concerns fall on deaf ears. She essentially tells you that these patients have been generated by her effort; therefore, you are to treat them as she requests. From an ethical perspective, are you responsible for treatment even though you are merely following her orders?
The grave impact of blind obedience was published in the early 1960s by Dr Stanley Milgram, who was intrigued by the appalling actions of the Germans who conducted brutal human experiments during the Holocaust. These experiments subjected Jewish prisoners and other targets of the Nazi regime to gruesome acts of torture. The procedures were labeled as efforts to promote medical knowledge, purportedly for the benefit of the greater population. These “studies” were conducted by German physicians who were pillars of their communities while civilians, but they were persuaded that their nefarious actions were constructive and justified. They obediently conducted vicious acts to inflict human suffering in response to orders from the Nazi command. Milgram wondered how such law-abiding citizens could be corrupted to commit these actions. He recruited participants who were instructed to administer a series of increasingly severe electric shocks to “students” as they responded to difficult questions. The plan was to deliver 30 shocks of increasing intensity, ranging from “slight ” to “severe” for incorrect answers, despite the student’s level of agony. Although many participants verbally objected to delivering the shocks, 65% reached the highest shock level despite their severe anxiety in inducing such torment.
In reality, the “students” were merely actors, the shock device was a sham, and the participants inflicted no pain on the students. Although the Milgram experiment is an extreme example, it illustrates the peril in indiscriminate obedience in matters involving ethical dilemmas.
Treatment that is dictated by colleagues but contradicts established levels of care incurs ethical and legal liability on the part of the treating orthodontist. As an accredited expert, the orthodontist is accountable for his or her actions and the treatment results. This also applies to situations in which the patient attempts to dictate a treatment plan. Refusal to participate takes a level of ethical courage that can be difficult to deliver. Rather than engage in further debate with your employer, you should exercise your autonomy and seek a practice opportunity elsewhere—as soon as you can.