No way out

Christie is your tennis partner’s daughter and will soon be married. She came to see you about 20 months ago with a crowded Class I malocclusion, which she wanted corrected before her wedding. You told her that the timing would be tight, but you’d do your best. You promptly placed her appliances and ordered the extraction of 4 first premolars.

Despite your best intentions, the treatment has taken longer than expected. By now, Christie has asked when treatment will be completed at each of her last 5 appointments. She increased her visit frequency to 3-week intervals in an effort to hasten progress, but it is apparent that you cannot provide a textbook result by her wedding date.

It is time to discuss this reality with her. You solemnly explain that the mesially inclined mandibular molars need to be uprighted because they remain tipped toward the extraction sites. She rejects your compromise to remove the anterior appliances for the wedding, asserting that she “wants no braces by her honeymoon!”

Three weeks before the wedding she calls the office and asks to be debonded as soon as possible. “I’ve had enough,” she says. “No one will see those molars, and my wedding will be the most important day of my life.” She assures you that she accepts the incomplete status of the treatment, stating that her teeth look far better than when treatment began. “As long as I won’t lose my teeth, I want them off,” she says. You reluctantly assure her that she will not lose her teeth, but the result is not typical of the quality you provide. You warn her that the result will be less stable if treatment is not completed. After a long pause, you agree to terminate her treatment and retain her dentition with aligners. You just don’t feel right about the debonding, but you realize that you have no other choice.

It is not uncommon to find ourselves in situations where an ethical dilemma necessitates a mutually exclusive decision between 2 choices. Once the decision is made and an apparent closure of the dilemma is achieved, a lingering sense of regret—or even mild distress—remains within us. We become frustrated because we cannot accommodate the conflicting needs of a situation. This remorse has been labeled a “residue of ethical regret,” which evolves after our decision has been consummated. A mental conflict over ethical or moral responsibility often ensues.

Conscientious people, including orthodontists, often face residues of ethical or moral regret. In some patients, we might never be able to achieve a bilateral Class I canine relationship despite our own efforts with the most cooperative patient. We might lament over our severe admonition of a young patient with consistently poor oral hygiene whose disarrayed family life relegates his home care to low priority. Even decalcification that lingers after debonding can arouse a “residue” in our minds, despite our concerted effort to avert the problem.

During my residency, I asked one of my favorite veteran instructors how he would describe the most salient quality of a good orthodontist. Although that was decades ago, I’ll never forget his response. He paused, fixed his eyes on me sternly for moment, and raised 1 finger in the air as he boldly declared, “A good orthodontist is an unhappy orthodontist.” I paused in thought, not immediately sure of what he meant. Then I saw the light: no treatment is perfect. Dissatisfaction with our treatment results involves a residue that indicates to us that we can always improve what we have done for our patients.

In Christie’s case, your conundrum involving her autonomy and your responsibility to maximize the good you provide for her is troubling. Whether her autonomy takes precedence over your beneficent efforts, or vice versa, you will need to live with your decision—along with a residue of regret. This might be one case that you cannot win.

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Apr 6, 2017 | Posted by in Orthodontics | Comments Off on No way out
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