4

CASE: THE DREADED ROOT CANAL

Roger Vianni is one of Dr. Clarke’s patients. For the past seven years he has constantly talked about his anxieties, the condition of his teeth, and what might need to be done about them. Dr. Clarke always responds calmly and sympathetically; she has learned that gentle words, however, are rarely enough to calm Mr. Vianni’s churning anxieties. His fear also heightens his sensitivity to pain and pressure, so local anesthetic has been needed for even superficial procedures. At each visit, he invariably tells a new story about an acquaintance who recently suffered some oral tragedy. He tells her at each visit how grateful he is that he has never suffered such a tragedy, especially the dreaded root canal.

Luckily, Mr. Vianni has not needed much dental work. But Mr. Vianni’s last visit was nearly a year ago, and this time he complains of severe pain in his upper-right jaw. On examination, Dr. Clarke first notices a fractured shallow amalgam in the upper-right second premolar; it simply needs replacement. More importantly, she also sees the likely cause of Mr. Vianni’s pain—a more sizable carious lesion in the adjacent first molar next to and under a large amalgam restoration placed before Mr. Vianni came to Dr. Clarke. There is, in fact, little sound enamel remaining. Examination of the radiographs confirms apparent pulpal involvement, with the treatment of choice being endodontic therapy and eventual full-coverage restoration.

Dr. Clarke is certain, however, that if she describes the root canal procedure and the drilling necessary for the crown preparation, Mr. Vianni will simply refuse. It’s not that he would rather lose the tooth or that he has financial or other reasons for not wanting a root canal and crown; he has often said he values his teeth greatly and is willing to spend whatever it takes to keep them healthy as long as possible. Yet he consistently reacts strongly to the thought of a drill and especially to the prospect of endodontic therapy. The fact that the procedure will resolve, rather than cause, pain and can ordinarily be completed without significant pain or discomfort will not change Mr. Vianni’s reaction. From her previous experiences with this patient, Dr. Clarke is certain that if she explains the situation he will either demand to have the tooth extracted or simply leave the office.

Luckily, Dr. Clarke mentions the simple problem with the premolar to Mr. Vianni as soon as she notes it, before looking closer at the first molar. He musters up his courage and agrees to its repair, “provided you freeze it up real good.” The first molar would easily be anesthetized with the premolar without Mr. Vianni knowing the difference. She could then proceed with the pulpectomy on the molar without Mr. Vianni having to suffer from the knowledge of what is going on until the parts he utterly dreaded are complete. She could also avoid lying to him since she could truthfully say that she is doing some superficial drilling on the premolar. She would, of course, tell Mr. Vianni the whole story of what she did to save him from anxiety and suffering as soon as the molar work is completed. At that point she could ask about his choice either to complete the root canal treatment and start a porcelain-fused-to-metal restoration (including the need of an interim temporary crown until the permanent crown is fabricated) or of a transitional amalgam buildup or even a tooth extraction (with or without various kinds of replacements) according to his preference. But that way he will not have to face the anticipation of starting a root canal procedure that he so much fears.

Dr. Clarke is almost certain that if she could describe the situation to Mr. Vianni—without him knowing it is in reference to his own mouth—he would understand and agree that endodontic therapy, along with proper restoration of the tooth, is the most reasonable and appropriate treatment and that he would be happy to pay the fees involved. The problem is that, in his own case, his judgment may be clouded by his anxiety about the idea of drilling and receiving root canal therapy in his own mouth. (While slightly anxious about the risks of being sued, Dr. Clarke is actually quite certain that Mr. Vianni would understand her judgment on his behalf and that the risk of a lawsuit in his case is merely hypothetical.)

Dr. Clarke is certain that Mr. Vianni trusts her to do whatever is best for him. She is also sure that if he could judge the matter objectively, Mr. Vianni would not want to suffer the anxiety of deciding about this treatment for himself. What good reason is there, then, for putting him through the pain of including him in this part of Dr. Clarke’s decision?

What should Dr. Clarke do and why?

THE DENTIST-PATIENT RELATIONSHIP

At the center of most issues in dental ethics we find a patient, a dentist, and a relationship between them, and we find a decision needing to be made about treatment or some other kind of professional action or intervention on the patient’s behalf. The previous chapter proposed that for every profession there is an Ideal Relationship between professional and client and that it is one of the most important norms of ethical conduct for members of that profession. What is the Ideal Relationship between dentist and patient? What are the proper roles of the patient and the dentist in the decision-making process that is so central to their dealings with one another? This is the topic of the present chapter.

Not all patients, though, are capable of making or participating in decisions about their treatment or other aspects of their health care. Some patients are young children or are severely disabled developmentally. Other patients suffer from other deficits that impair their capacity for decision-making. It will be important to carefully examine what a person needs in order to participate effectively in a decision-making process and what sorts of deficits justify a doubt about someone’s capacity to do this. These matters will be addressed in detail in chapter 7 along with the question of how a dentist ought to relate to patients who exhibit such deficits, whether their capacity for decision-making is only partially diminished or whether they cannot participate at all in decision-making about their dental care. The focus of this chapter, however, is on the dentist-patient relationship in situations where the patient is capable of making an autonomous choice in the decision-making process with the dentist.

There is no single English word that means the same thing as “capable of making an autonomous choice.” But this is a cumbersome phrase to repeat over and over. There is a word in ordinary usage that expresses this idea: “competent,” along with its noun, “competence.” Unfortunately, this term has an important technical meaning in the law that is quite different from its commonsense meaning. In the law, anyone who has reached the age of an adult (as defined or stated by law) is competent; that is, a person who has reached the legally determined age can make decisions and take actions that have legal standing and can do so unless a judge in court rules that this person is no longer able to do so. Thus, a person who is permanently comatose is still legally competent until the person is declared incompetent by a judge, or other designated legal authority, after an appropriate hearing and not before then. Similarly, with a few exceptions, a highly intelligent, thoughtful, sensitive seventeen-year-old is, in the eyes of most state laws in the United States, as incompetent to make health care decisions as an infant. So using the word “competent” can lead to some confusion.

It seems best, therefore, to reserve the terms “competent” and “competence” as well as “incompetent” and “incompetence” for legal contexts and to use them only in their technical legal sense. Therefore, the word that will be used throughout this book as shorthand for the phrase “capable of making an autonomous choice” will be “capable,” and the noun “capacity” will be used for the phrase “capacity for autonomous choice.”

In this chapter, decision-making by dentists and capable patients will be examined under three headings. First, four possible models of the patient-dentist relationship will be examined and an account of the ethical implications of each in the decision-making of a patient and a dentist will be compared.

Second, the principle of respecting autonomy will be examined. The notion of autonomy is particularly relevant to decision-making and is a central moral principle in the culture of the United States as well as in many systems of moral philosophy. In the course of examining this principle, we will also ask whether circumstances ever justify violating someone’s autonomy precisely for that person’s benefit, a pattern of thinking and acting that is sometimes called paternalism. That is, could a dentist ever be morally justified in violating a patient’s autonomy for the sake of the patient’s oral health? (Admittedly, doing so could put the dentist at legal risk. But even so, avoiding legal risk is no guarantee that moral error will be avoided. Sometimes morality requires a person to take a serious legal risk, so the question of whether paternalism is ever morally justifiable still needs to be asked.)

The third way of addressing the issue of the proper relationship between dentist and patient will focus on the moral norm of telling the truth and the principle of Informed Consent/Refusal that currently describes the legal minimum for the dentist-patient relationship. This will also be the place to talk about patients’ trust. For the kind of relationship that a dentist should strive for in order to earn and maintain their patients’ trust is, as will be explained, an Interactive Relationship.

FOUR POSSIBLE MODELS
OF THE DENTIST-PATIENT RELATIONSHIP

The dentist-patient relationship can be conceived according to many different models, of which four seem the most important. These will be explained and compared, and the case will be made that one of these, the Interactive Model, describes the Ideal Relationship between a dentist and a capable patient. The four models to be examined are the Guild Model, the Agent Model, the Commercial Model, and the Interactive Model.

It is obvious that a dentist’s ability to establish an Ideal Relationship with a given patient will depend on how the patient responds to the dentist’s efforts. Actual relationships will vary, but the Ideal Relationship that the dentist strives for should not. The four models described here present very different pictures of the relationship that the dentist ought to be striving to bring about, and only one of them can properly be thought of as the Ideal Relationship from the point of view of dentistry’s professional ethics.

The Guild Model

In the Guild Model, the dentist is the only active party in decision-making, and the proper role of the patient is to be completely passive and to accept whatever decisions the dentist makes. This model focuses exclusively on the dentist’s expertise and the patient’s utter lack of it. The dentist obviously has the ability to understand and explain the patient’s condition (diagnosis), to predict various future paths that might be taken under various circumstances (prognosis), and to intervene with treatments and other forms of care in order to maximize various aspects of the patient’s well-being in the outcomes (therapy). But in the Guild Model the dentist is also considered to know everything else relevant to determining what is best for the patient. The patient not only lacks the theoretical knowledge, skills, and experience that enable the professional to apply his or her expertise effectively in each particular set of clinical circumstances, but, in addition, in the Guild Model the patient is viewed as having nothing at all to contribute to judgments about what is best for him or her. What the patient values and how the patient would prioritize possible treatments or other interventions the dentist might undertake is deliberately excluded from consideration in the Guild Model. In the Guild Model, the dentist makes all of the value judgments and determinations of need.

Therefore, in the Guild Model, the proper role for the patient in all important aspects of dental decision-making is that of being one to whom things are done. For the patient in this model is considered to be simply unable to understand what would contribute to his or her well-being and is, therefore, unable to make any important contribution to dental decisions about his or her situation.

But the Guild Model does not see the dentist as an independent expert. In the Guild Model, the source of the dentist’s technical expertise and value judgments about patients’ well-being is the dental profession—that is, the community of dentists who preserve and advance dental knowledge and practice and are committed to the central values of oral health care. It is the profession that trains and then certifies that the individual practitioner is qualified to assist patients and make dependable judgments about what is best for them. It is the profession that determines the fundamentals of how individual dentists should act toward patients, both therapeutically and ethically. In addition, in the Guild Model it is the profession and the profession alone that determines the specifics of a dentist’s obligations to patients. Since those who are not dentists are viewed as having no understanding of oral health or their need for it, the Guild Model has no role for the larger community either in the creation of a profession to begin with or in determining the contents of a profession’s ethics. Similarly, in the Guild Model, the individual dentist undertakes his or her professional obligations not by making a commitment to the larger society but solely by a commitment to the profession.

There is a serious moral problem with the Guild Model in the eyes of many people, including many dentists. One way to state this problem is to point to the Guild Model’s failure to respect the autonomy of patients who are capable of autonomous decision-making. For, according to the Guild Model, a dentist is to treat patients as if they were not capable of autonomous decision-making when they are. Doing so is obviously a violation of the patient’s autonomy.

The principle of respecting autonomy and the question regarding whether it may ever be justifiably violated for the sake of the patient will be examined more fully in the next section. But there is one response to this objection to the Guild Model that deserves immediate consideration. Even if these patients are capable of autonomous decision-making in other respects, the defender of the Guild Model would respond that they still do not have the dentist’s knowledge and skills in regard to oral health, which are precisely what they will need if they are to be capable of making decisions about their dental care. In addition, patients are often in pain or in considerable distress as well. Therefore, the defender of the Guild Model concludes that it is the dentist who should be making all the decisions because the relationship is inherently asymmetrical or unbalanced in this way.

What the Guild Model fails to account for is that there are important components of every dental decision that are not included in the expertise of even the most acutely trained and extensively experienced dentist. The reason for this is that therapeutic alternatives are never value neutral. All therapeutic choices involve selecting one set of life experiences for the patient over another set, and the knowledge and skills that the dentist brings to the situation are not adequate tools for comparing the value of these possible experiences within the patient’s life. Instead, the patient’s own values must also be brought to bear in the choice of dental interventions. But only with the patient’s participation in the dental decision will the patient’s values dependably direct that decision.

Therefore, the Guild Model’s picture of the patient as the passive recipient of expert dental interventions does not fit the ethical reality of patients and dentists in their actual relationships. In fact, as will be explained in chapter 7, the Guild Model does not even adequately portray the dentist’s proper role in treating patients who are not capable of autonomous choice. For these reasons, the Guild Model should not be considered to be the Ideal Relationship for ethical dentist-patient relationships.

The Agent Model

A second model of the dentist-patient relationship reverses the dentist’s and patient’s roles from the Guild Model. In this second model, the most important aspect of the decision-making activity in dental care—determining what values should shape and control the decisions—is assigned entirely to the patient. Here, the professional simply puts his or her expertise at the service of the patient’s aims and values. The dentist’s task is only to give effect to the patient’s values and the patient’s choices made on the basis of those values, responding as efficiently as possible to fulfill the patient’s choices based entirely on the patient’s goals and values. The dentist is to act, in other words, only as an agent for the patient. Hence, this is called the Agent Model.

This model is not often discussed in regard to dentistry or the other health professions—probably because it severely misrepresents our ordinary understandings of a health professional’s ethical commitments. The professional example most commonly discussed in terms of the Agent Model is probably the image of the lawyer as a “hired gun,” but the Agent Model is no more defensible as a description of the lawyer’s ethical commitments than it is of the health professional’s commitments. As an example from health care, imagine a dentist, physician, or nurse who agrees to use his or her access to controlled substances to meet the desires or needs of a patient’s addiction simply to serve the patient’s choices more completely, without asking how that action connects to the other elements of that patient’s well-being that the society believes the health professional is committed to fostering.

The failure of the Agent Model is that it simply sets aside the idea that each profession has certain values that it is committed to fostering for those it serves through the use of its expertise. These values, which are called Central Practice Values in this book, will be examined in detail in the next chapter, where the role of these values in the dentist’s professional-ethical decision-making will be explained. The Agent Model simply ignores the values to which the dental profession is committed even though these are central elements of how the dental profession functions ethically in our society.

A patient’s own values and conception of his or her well-being certainly does have an important role to play in decisions concerning the dental care he or she receives. But these are not the sole determinants of how dentists, striving as committed professionals to bring about the Central Practice Values of their profession for their patients, are to act. Therefore, the Agent Model must be rejected as a candidate for being the Ideal Relationship between dentist and patient.

The Commercial Model

The weaknesses of the Guild Model and the Agent Model have prompted a number of people to turn to the Commercial Model to replace them. The consumer movement in health care, as well as proponents of a still-wider role for free enterprise in our health care system, claim that the Commercial Model is the best guide for health professionals, including dentists, to follow in their relationships with patients.

According to the Commercial Model, in contrast to the Guild Model, the patient is indeed a decision-maker about his or her health care and, in contrast to the Agent Model, the dentist is also a decision-maker with his or her own professional values to pursue rather than functioning as a mere agent of the patient. In these respects, the Commercial Model may appear preferable to each of the others. Yet other features of the Commercial Model make its claim to be the Ideal Relationship problematic.

According to the Commercial Model, a member of a profession is simply another producer selling his or her wares in the marketplace. Thus, a dentist has a product to sell, and patients may want to buy it. The two parties may make whatever agreements with one another that they are willing to make. By the same token, both the dentist and the patient may refuse any arrangements that either one chooses to refuse. In other words, according to the Commercial Model, the only moral norms that apply to dentistry are those that apply to every other bargainer in the marketplace. These norms require that marketplace bargainers not coerce, cheat, or defraud one another, and they are obligated to keep the contractual commitments they freely make with others. Beyond these obligations, according to the Commercial Model, the dentist has no other obligations to any patient except such obligations as the dentist and the patient voluntarily undertake. According to the Commercial Model, in other words, there are no specifically professional values or obligations on the part of the dentist; there is nothing to which a dentist is obligated because he or she is a professional.

In addition, as in all market relationships, in the Commercial Model the dentist and the patient are first and foremost competitors. That is, each is trying to obtain from the other the greatest amount of what he or she wants (money, satisfaction, effort, time, and other aspects of well-being) while giving up in the exchange as little as possible of these things. The dentist is concerned about the patient’s well-being only as a means of improving his or her own interests and fulfilling his or her desires. Thus, the dentist has no obligation to any patient to preserve or foster the patient’s oral health or any other aspect of the patient’s well-being until the dentist specifically contracts to have such an obligation. For this reason, no patient should presume that a dentist has such an obligation or commitment in advance of a specific contract to this effect between the dentist and that patient. At the point when the patient is seated in the operatory chair, then, the patient and dentist are first and foremost competitors.

In the Commercial Model, furthermore, the patient’s need for care is not a direct determinant of a dentist’s actions. The patient’s need has no special ethical import for the dentist, and there is certainly no antecedent obligation to meet a patient’s needs; there are only whatever obligations the dentist and patient subsequently negotiate regarding their relationship. Need does function, of course, as a potent motivator for patients to seek and contract for dental care. As such, the dentist can effectively use the patient’s needs to market his or her services to the patient. But in the Commercial Model, when a dentist says to a patient, “this procedure will answer your need for . . .” these words should not be received by the patient with any special degree of trust, no more so than would the comments of a person selling anything else. That is, trust that the dentist has the patient’s oral health or any other aspect of the patient’s well-being as a primary goal has no place in the Commercial Model’s view of their relationship.

Obviously, in this model the patient is not a passive recipient of expert professional services, as in the Guild Model. The patient first judges the value of the information that the dentist can supply and then chooses whether or not to be guided by it. Then, after judging alternative courses of action on the basis of this information, the patient judges the value of various therapeutic interventions by the dentist, or others, and chooses either to purchase them or not. The patient in the Commercial Model is regarded as an example of Homo economicus, the rational consumer, who weighs all the elements of cost and benefit relevant to a given exchange and chooses the available product or service that yields the best combination of these or else chooses not to purchase anything at that time.

The Commercial Picture of dentistry as a profession was rejected in chapter 2. But it might be possible, or at least not simply contradictory, for the members of a normative profession to have a commercial relationship as their Ideal Relationship with those they serve. Because a number of authors, including a number of dentists, propose that this model describes the Ideal Relationship, this proposal deserves careful examination. First, is the Commercial Model a realistic possibility for the relationship between patient and dentist? Second, if dentists and patients could realistically function in this way, does the Commercial Model describe the Ideal Relationship between them?

The extent to which patients not comprehensively trained in dental science can understand the subtle differences between alternative oral conditions and alternative interventions to address them is very limited—even if they have obtained a great deal of accurate dental information from reliable sources. The key point, here, is that dentistry’s patients have not had the benefit of dental practice—that is, using expert information to respond dependably and effectively to patients’ oral health needs. For practice experience is every bit as important in forming good dental judgments at chairside as scientific theory and familiarity with the current literature. It is therefore a legitimate question to ask whether the average patient can realistically play the rational consumer’s role in comparing alternative therapies.

Another consideration is that many patients in our health care system do not contact a dentist until they believe refusing dental care is no longer an option. But it seems clear that one cannot function as a rational consumer, comparing all alternatives in terms of cost and benefit, if one has already set aside the option not to buy at all. The rational consumer must be able to leave the relationship if none of the products offered is on his or her list of optimal cost-quality exchanges.

One response to these arguments is that dentists ought to be more effective at communicating with patients; that is, dentists should give more attention to patient education (which is not the same as sales information). But this response, in fact, already begins to view the patient-dentist relationship as having the patient’s oral health as a primary goal, and that is not how the patient-dentist relationship is viewed in the Commercial Model. The most that the Commercial Model can say is that the dentist who communicates and educates better has a better information product to sell and will ordinarily sell more of it for a better price. But that is very different from saying that the dentist has an obligation to communicate and educate effectively because of the ethical importance of effective patient decision-making for the patients’ oral health. If one says that dentists ought to be more effective at educating and communicating with patients, this points to a different picture of the patient-dentist relationship from the picture offered in the Commercial Model. This other picture sees the dentist and the patient working out their judgments and choices about the patient’s oral health together, to the extent that this is possible under the circumstances, rather than competing so each is trying to maximize only his or her own gain.

Another negative aspect of the Commercial Model is that patients ordinarily view life and health as values much too important to put them into the hands of someone who is simply a competitor. The actual reality of the patient-dentist relationship is therefore unavoidably more than one of competition. Even if the dentist tried to be simply a competitor and the patient was intensely competitive, it is doubtful—with the patient’s health at stake—that they could maintain a relationship on these terms for long or that patients’ trust in their dentists would be fostered under such circumstances. When looked at carefully, the Commercial Model clearly does not describe the Ideal Relationship between dentist and patient.

At the same time, this should not drive us back to the Guild Model, because what counts as the patient’s well-being is not something fully known by the dentist, either by training or by experience. The dentist’s commitment to the goal of fostering important aspects of the patient’s well-being can only be carried out through empathetic communication and a shared judgment and a shared choice with the patient. The point, then, is not only that the Commercial Model and the Guild Model each falls short; it is that some sort of shared judgment and choice between dentist and patient is what ought to characterize the dentist-patient relationship, and the question is what kind of relationship is most likely to lead to this shared decision-making most effectively.

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