Your new adult patient, Amy, is remarkably attentive to detail. A self-employed jeweler, she is known in the city for her creative, meticulously executed pieces that command healthy fees. She was referred to you by a top-level prosthodontist to address her concern of mandibular anterior crowding. He advised you to “Leave some extra time for her initial examination because you’re going to need it.”

Amy arrives at precisely the appointed time, dressed and groomed impeccably. Although her posterior occlusion and maxillary alignment are ideal, the maxillary lateral incisors are undersized. The mandibular right central incisor is totally space deficient. She wants to know whether extraction of the incisor is an option in resolving her concern. She is absolutely opposed to maxillary tooth movement of any kind. You suggest records production and a diagnostic wax-up to further explore the extraction possibility.

The wax-up shows a fine anticipated result. You explain the possibility of gingival embrasure spaces with options in remediation, as well as all you can about your treatment plan to extract the mandibular central incisor. Although you do not mention the inevitable maxillary-to-mandibular midline discrepancy, the anterior teeth couple ideally on the wax-up. Amy approaches you with a volley of questions about the plan, including the necessity of each radiograph, bracket choices, retention options, and final restorative procedures. After approval of your consent form, she announces that she will proceed with correction.

Treatment goes smoothly, and the final result is superb. But instead of overwhelming delight in her appearance at her debonding visit, she says that she is somewhat disappointed. She points to the maxillary-mandibular midline incoordination and states that this “annoys” her. She asks why you didn’t inform her of this relationship before her treatment began.

Informed consent is a component of the ethical principle of autonomy. To be effective, informed consent must involve a patient or parent who demonstrates competence. Competence in an ethical context is defined by a patient’s ability to understand the information presented during disclosure of a treatment option. If a patient has insufficient intellect to understand the treatment or receives an explanation that is beyond his or her comprehension because of overly technical descriptions, the patient is incompetent to exercise autonomy.

Consent can be classified in several ways. The traditional “professional standard” requires the provider to disclose all facts and conditions that other professionals would mention in a similar case. The deficiency of this standard is that these explanations might not give the patient adequate information to make a fully informed treatment decision. Alternatively, many contemporary ethicists advocate the “reasonable person standard,” which requires the provider to disclose all information that a reasonable person would find meaningful in deciding whether to accept or reject a treatment plan. Another classification is the “subjective standard,” which requires the clinician to augment the routine explanation of treatment for those patients who request further elaboration. Such disclosure is intended to address the unique requirements of some fastidious personalities. Subjective disclosure can involve significant amounts of time and effort because answers to one question might open others.

As specialists, we see many individuals or families who can be quite demanding. This might be one reason that they find their way to our offices: patients who are less discerning could be treated elsewhere instead of referred for specialty care. Informed consent, often at a subjective standard level, then becomes essential—and should be thoroughly documented in the patient’s treatment record.

Your answer to Amy regarding the midline discrepancy is no less difficult but is as essential as ever. You can only hope that your diagnostic setup is in pristine condition because you’ll need it now. In this case, you hope that a picture will be worth a thousand words.