A recently retired dentist who had been your best referrer for decades asks you to evaluate his wife for orthodontic treatment. She is a distinguished 64-year-old woman whose complaint is progressive crowding of her mandibular anterior teeth. She has a thin biotype with elevated bleeding indexes. There is no question that her periodontal susceptibility is significantly elevated, but she says that her husband has managed her periodontal health for decades. You hesitate to comment further but instead tell her that you’ll be in touch with him soon.
An ethical conundrum: You certainly won’t treat her without specialty cotherapy, but you must inform her dentist (ie, her husband) of her periodontal involvement. Although he had not identified her periodontal susceptibility during his extended management of her dental health, your primary concern is to “first do no harm” if orthodontic treatment is initiated. Would the Hippocratic Oath have some application in this instance?
Hippocrates, a Greek physician, was born about 460 bce . The Hippocratic Corpus is a collection of medical texts attributed to Hippocrates, although it is not known whether he wrote the entire document himself or whether his followers wrote it after his death. One well-known article in the corpus is the Hippocratic Oath.
I swear by Apollo . . . to keep according to my ability and my judgment, the following Oath and agreement:
To consider dear to me, as my parents, him who taught me this art; to live in common with him and, if necessary, to share my goods with him; To look upon his children as my own brothers, to teach them this art; and that by my teaching, I will impart a knowledge of this art to my own sons, and to my teacher’s sons . . .
I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
I will give no deadly medicine to any one if asked, nor suggest any such counsel; and similarly I will not give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing and all seduction and especially from the pleasures of love with women or with boys, be they free or slaves.
What I may see or hear in the course of the treatment . . . in regards to the life of men . . . I will keep to myself holding such things shameful to be spoken about.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all humanity and in all times; but if I swerve from it or violate it, may the reverse be my life.
Although these words were originally applied to medicine, perhaps they have some relevance to 21st-century dilemmas as “the 6 keys to ethical orthodontics.”
Correlate these Hippocratic ethical principles to this situation:
Respect the educators and senior practitioners (gratitude). Respect senior practitioners and be especially grateful to those who taught you the art and science of orthodontics.
Do no harm (nonmaleficence). Be aware of your own potential. Avoid procedures that might harm your patients.
Do good (beneficence). Act in the patient’s best interest. Always explain your treatment plan thoroughly. Remember that you are not just treating a malocclusion; most importantly, you are treating a person.
Self-awareness (beneficence and veracity). Never hesitate to refer a patient when necessary. Complicated clinical problems might be best treated in a university or a hospital setting. Don’t be afraid to say “I don’t know.” It is an honest statement.
Professionalism. Avoid becoming personally involved with your patients. Respect their vulnerability. The orthodontist is responsible for establishing a “neutral safe zone” where patients can benefit the most.
Confidentiality (fidelity). Do not disclose any private information, either deliberately or accidentally.
Although the Hippocratic Oath is the basis of contemporary Western ethical codes such as that of the American Medical Association, some ethicists have criticized the oath. Its emphasis on paternalism has been questioned. Paternalism allows the provider to act on the patient’s behalf without the patient’s input. In contrast, the principle of autonomy respects the patient’s right to make decisions after receiving full disclosure of the treatment options, risks, and benefits. The word autonomy is derived from the Greek words autos (self) and nomos (law), and reflects such liberty.
Another concern of contemporary ethicists is the oath’s perspective on confidentiality. The Hippocratic tradition encourages the physician to provide confidentiality, including the withholding of relevant facts; but some patients will want to know the prognosis of treatment or their status, regardless of the severity or the consequences. Those who advocate patient autonomy will consider the act of withholding a dire prognosis, the absence of obtaining informed consent, or the omission of alternative treatment options as inappropriate violations of a patient’s rights. Finally, although the classic appeal of the Hippocratic Oath has been attributable to its parallel to Western religious and philosophical traditions, localized cultural perspectives in other areas of the world have influenced the development of ethical codes irrespective of the Hippocratic Oath.
How will “the 6 keys of ethical orthodontics” guide you in this dilemma? You still need to communicate with the patient’s trusting husband—the practitioner whom you have respected for decades as a collaborator and senior colleague. Perhaps seeking the patient’s permission to discuss her treatment with a trusted periodontist and a restorative dentist is your first step. After a collaborative treatment plan has been established, a review of the diagnostic records with the patient, her husband, and the other 2 dentists is in order before any treatment commences. You’ll gently identify the patient’s bone loss and seek a protocol for future prevention or remediation before tooth movement is initiated. The patient will also learn of her restorative and orthodontic needs before a single bracket is placed. There’s no need to discuss the past at this point. It’s all about moving forward from here.