INFORMED REFUSAL

I find much inspiration from reading the American Journal of Orthodontics and Dentofacial Orthopedics journal (AJO-DO) and particularly enjoy the thoughts within the articles on ethics in orthodontics. As a generalist my perspective is a little different but the complex arguments are worth pondering.

The author discussed a situation where a patient previously had orthodontics and was interested in more improvements. She was absolutely refusing the ‘ideal’ choice of orthognathic surgery and didn’t even want to wear braces again. The discussion included the importance of fully explaining the choices and it was referenced that “Informed refusal can occur for various reasons. Previous experiences, prejudices, religious beliefs, cultural lore, financial limitations, phobias, or simply a whim might be sufficient grounds for a patient to reject the ideal option and choose a significantly compromised alternative.” (Weinstein BD. Informed consent and refusal. In: Cooke DB, editor. Dental Ethics. Philadelphia: Lea and Febiger; 1993. p. 76-7)

We use the term ‘ideal treatment’ all the time but the textbook results often come with greater risks, costs and time. If this is the case, we may be imposing our desires to be providing board certified results on patients who only discover the risks during the few minutes of time used to read over the fine print of a treatment consent form.

With specialists concern about ‘practice creep’ or overlapping generalist and specialist services, this discussion has become polarized. Generalists who are busy and ethical are more likely to suggest second opinions. Those that do not feel the love within the dental circle are less prone to give the patient a balanced presentation. I know there are ways we can all work together and it will be interesting to see how these adventures unfold.

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