It’s not the first time it has happened. You have just examined a 15-year-old boy who was brought to your office by his mother after referral by his general dentist. The referral was delayed because of lagging dentitional development; the maxillary canines have finally emerged, but these teeth are too rotated to correct with removable appliance therapy. You suggest ceramic fixed appliances, but the patient vehemently objects. He asserts that the appliances would be “social suicide.” His mother attempts to convince him of the advantages of prompt correction, but his obstinacy grows. Your most sincere effort to reason with him is met with only contention. You politely suggest that the discussion be postponed until the family arrives home. His mother’s departing words to you include an apology for the boy’s behavior and her firm assurance that he will indeed proceed with therapy.
Autonomy is a person’s ability to make decisions based on his or her own needs, desires, or judgments. The word is derived from the ancient Greek word auto , translated as “one’s own,” and nomos , meaning “rule or law.” Autonomy is the basis of informed consent, which enables patients to accept or decline treatment for themselves. Autonomy is also seen as respect for the person’s right to decide what best meets his or her own needs.
Not everyone has the luxury of autonomy; it is limited for some, including minors, convicted criminals, and those who have been declared incompetent on the basis of impaired mental capability. But successful orthodontic treatment is highly contingent upon mutual cooperation between doctor, patient and parents, and is best accomplished with a patient’s full consent to proceed with correction. In the words of a former professor, “Orthodontic therapy is a 3-legged stool: if one leg fails, it’s total catastrophe!” Given the reliance upon cooperation that can evolve from autonomy, should our patients, many of whom are minors, be granted the autonomy to decide whether to proceed with orthodontic therapy?
As dentists, we are educated in behavior management techniques that are intended to facilitate care delivery to patients of all ages. After all, what we do for a patient has immediate clinical consequences, whether the presenting complaint is an acute periapical abscess or a deep bite Class II malocclusion. Yet our approach to a patient’s anxiety or our attitude toward his refusal to proceed with treatment can have a profound effect on that patient from other perspectives. Forcing an unwilling adolescent into several years of orthodontic therapy might have consequences that can affect his relationship with future health care providers for decades.
The decision of whether to decline or proceed with elective orthodontic therapy despite a patient’s objections must be based on many factors. Most would agree that those few orthodontic problems that require mandatory correction are cases in which a young patient’s autonomy should be overridden by his parents. In the absence of a handicapping problem, however, other issues, including the patient’s level of interest and self-motivation, should involve the patient’s autonomy. Allowing a minor to make the decision to initiate care is more appropriate in orthodontics than in other branches of medicine and dentistry. Perhaps a delay in starting treatment after discussion with the patient and his parents is the strategy of choice. The elective nature of our services and the vast component of cooperation involved in orthodontic therapy necessitate respect for the patient’s input. If the young patient chooses to postpone or decline elective treatment after the orthodontist has made a sincere, compassionate effort to explain the benefits of therapy, the patient’s autonomy to decline treatment should be respected.
As the old adage says, “You can lead a horse to water, but you can’t make him drink.”