Ethics can sometimes feel so esoteric. It is discussed in broad realms and general terms. Ethical issues can sound impersonal or vague. Technical or legal terms are often utilized to delineate concepts. They remind some of us of catechism classes with rigid, rote canons to follow. In reality, ethics is a most intimate and personal aspect of our personal lives. The day to day, case by case application of ethics has a way of evolving beyond definitions, and possibly accounts for the broad general descriptors.
The laundry list of difficult choices we make or help our patients make can feel daunting. Which option is best?
• Repair versus replace
• Cost versus outcomes
• Time versus productivity
• Patient goals versus doctor’s preference
• Material choices and cost
• Charges for repairs
• Frequency of visits
As practitioners, we must seek to avoid the trap of pre-judging our patients and their options. Past choices do not assure the direction of future treatment. Financial resources are not always related to decision making. Anticipated longevity of the patient should not reduce the scope of options offered. Of course, short term expense versus long term results needs full consideration. Informed consent dictates no less. We cannot trust the history of prior conversations we have had with a given patient. This is where personal contact is most critical. It is not easy to provide a non-judgmental environment for patients to express their wishes or desires while sharing personal limitations.
There can be value in asking a patient if he or she has obstacles to the proposed treatment — i.e., cost, fear, time, lack of comfort, compliance, or confidence. These conversations do not always fit into our scheduling, and can force us to switch gears during a busy, demanding day.
Great clarity is even more crucial when dealing with incompetent or marginally competent patients. If treatment options result in blank stares or inappropriate questions, it may be worthwhile involving another family member or designated adult. For minors or other guardianship issues, group discussions or separate conversations with guardians are important but need to occur within HIPPA guidelines. Try to secure signed authorizations to simplify and facilitate treatment. Sometimes we need to act as mediators between the two involved parties to reach agreed upon treatment goals. The urgency of youthful wishes, balanced by the financial realities of their concerned guardians, can be one such challenge.
The concept of “Informed Refusal” can also feel like murky waters to navigate. Emphasis on possible outcomes of not accepting treatment becomes more important. The use of signed or initialed refusal is fairly commonplace, and recommended. Obtaining a signed refusal does not, however, release the dentist from responsibility for providing a standard of care. The journey into possible supervised neglect can be perilous and difficult to defend in litigation. Refusal of necessary care (i.e., needed radiographs) can lead to the choice to dismiss a patient from your practice. Any dismissal needs to follow guidelines established by your State Board of Dentistry. Fortunately, most patients who realize that your commitment to provide quality care exceeds their financial value to your bottom line reconsider their choice.
Experience can be a great teacher. Rehearsing or scripting conversations can save time and ensure that proper informed consent takes place. The use of written materials or brochures can enhance clarity and improve consistency. Avoiding unpleasant topics, while tempting, is never in the best interest of your patient or your practice. Plain talk leads to clear thinking and easier decision making. A personal relationship between you and your patients is the best avenue to success.
*Dr. Kurkowski is Chair of the Minnesota Dental Association Committee on Ethics, Constitution and Bylaws. He is a general dentist in private practice in Saint Paul, Minnesota. Email is email@example.com.