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My question concerns the increasing number of ethical conflicts I and other dentists are confronting involving "extreme makeovers." Some patients request a makeover, in spite of the fact that none of their teeth has a single blemish. They want a Julia Roberts smile. I have recognized the shift toward cosmetic procedures during the past decade. Obviously, a significant income can be generated by performing this type of service. However, I also have listened to respected speakers who note this trend and question the destruction of healthy tooth structure solely for cosmetic reasons. What is the position of the ADA’s Principles of Ethics and Code of Professional Conduct regarding this increasing trend?
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These makeovers may require resolution of many conflicts, both with our patients and within ourselves. We must make overlapping ethical, professional, business and risk management decisions with every patient we see. However, those decisions, and their potential conflicts, seem to be taken to a new level with the advent of the "extreme makeover" patient.
From an ethics point of view, each of the five principles reflected in the ADA Principles of Ethics and Code of Professional Conduct may need to be evaluated when we consider doing a makeover. The principle of patient autonomy (self-governance) is cited first by many dentists, determining only that the makeover is "what the patient wants." This certainly is one major factor. Dentists, however, must realize that they have a great deal of "power" or influence over those patients’ decisions because of their knowledge and skills. In addition, many patients understand neither the complexity of makeover treatment nor the consequences involved. They may not realize that their "wants" often conflict with their "needs."
The second principle, nonmaleficence (do no harm), also is implicated. Often these patients want crowns or veneers when an equivalent outcome might result from orthodontics and bleaching, saving healthy tooth structure. Do they understand that the first preparation on a tooth may be the precursor to the second and the third? Do they understand that they need a healthy periodontal foundation on which to build? Are they able and willing to spend the time and effort to maintain these extensive restorations—for a lifetime? Are your knowledge, skills and experience (and you need to evaluate this objectively) at a level that is commensurate with the skills needed not only to treat these patients but also to maintain what you have done?
The third principle, beneficence (do good), might be better served in many of these extreme cases by suggesting less invasive treatment options. Some patients expect a permanent psychological boost from their makeover, perhaps even a radical lifestyle change such as that seen on television. Lowering their goals to a more realistic level may be the "best" change you can make for them.
According to the fourth principle, justice (fairness), the dentist has a duty to treat people fairly. Will the clinical procedures performed be fair for this patient, on the basis of what the patient wants or desires? This principle also includes the admonition that dentists should not be unjustifiably critical of other dentists. This would be especially applicable if such criticism is used to influence the patient to proceed on the basis of that criticism.
The last of the five ethical principles, veracity (truthfulness), may be the most important conflict to resolve, as it consolidates and summarizes all the conflicts of this ethical mix. Are you careful not to raise the patient’s expectations to a level that you (or anyone) may never achieve? Have you made it clear that all of this work may have to be redone eventually? Does the patient know that endodontic treatment may be needed for these crowned teeth later, if not now? Have you discussed with the patient the very high present cost, as well as the future financial implications? Will your patients expect you to do everything, including the implants, periodontics and endodontics? Would you do this for your spouse, children or parents?
Be honest about your motivation, at least with yourself. Is this a way to feed your ego, increase your income or become well-known and admired around town, or is it to provide a needed service?
Your patients must recognize not only the potential good an extreme makeover can do, but also the potentially serious problems that can arise, now and in the future. Only then can they make informed and realistic choices about extensive, optional treatment that cannot be undone once it has begun. Remember, these makeovers are called "extreme" for a reason.
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