Ethics and aesthetics part II

Ethics and aesthetics part II

The second of two articles on ‘ethics and aesthetics’ looks at some of the key considerations that can help to reduce dento-legal risk when providing cosmetic dentistry, particularly in relation to patient expectations.

The importance of communication in all types of clinical care cannot be overstated. With respect to cosmetic treatment, careful attention to this is absolutely key to understanding what the clinician has been called upon to deliver. What the clinician sees, assesses, and measures in terms of the clinical presentation, and indeed the technical outcome, also needs to be seen through the eyes of the patient. It is, after all, the patient’s view that will decide if the treatment is successful in terms of achieving their desired outcome.

‘Need’ versus ‘want’
Treatment that is ‘needed’ in the clinical sense can be assessed by the clinician and will, by and large, be defined by the attention required to address the damage or pathology present. Cosmetic treatment, on the other hand, is generally elective, and as such chosen to satisfy a ‘want’ on the part of the patient.
It is important to bear in mind this fundamental distinction. The ‘expectation difference’ between an intervention intended to repair something and one that is carried out to improve the appearance of something that is intact to start with, can be quite marked. Fixing something broken has a clear end point. Improving something that isn’t broken does not.
In providing treatment of any sort, both dentist and patient need to know what the aim is. Treatment addressing an issue based upon what the patient desires rather than needs requires needs very careful consideration. Back to primum non nocere and all that.
A clinician can assess need, but only the patient knows what they want. This can be complicated by the fact that some patients are unable to communicate this accurately so it can sometimes appear as if the patient themselves does not know what they want. The danger here is that a clinician faced with this situation may be tempted to use their skills in ascertaining need to identify what they feel the patient wants, or should want, based upon their clinician’s perspective.
This approach is perfectly understandable, given our professional grounding in diagnosis and appropriate intervention. However, it can result in misunderstandings from the word go. If so, this will be destined to produce disappointment at a later date when it becomes clear that both parties were aiming towards different destinations.

Working towards a shared understanding
In cases where there is any doubt at all about what the patient is really after, it is essential to delay treatment until both sides have a crystal clear understanding of the destination. There should also be a clear grasp of when this will be reached and what it will cost. It may take time to arrive at this shared understanding, but the time committed to this may avoid much delay, inconvenience and frustration at a later date. So, whichever resources are available to assist in achieving this should be used. This could be printed materials, images, videos or other visual aids.
Shared understanding and agreement are, of course, all part of the consent process. Clearly, the patient needs to know what the treatment will involve, which means they should know what the treatment plan is. As every dentist knows, however, despite our best efforts, treatment does not always go according to plan and adjustments occasionally need to be made to accommodate unforeseen difficulties.

Managing the ‘impatience factor’
If there is any sort of hitch during cosmetic treatment, for example a delay with the laboratory work or a need for some procedure to be repeated, it is essential to inform the patient as soon as possible. It has to be remembered that treatment that is wanted by a patient will always have a built-in ‘impatience factor’. The effect of this will be a tendency for the patient to be less forgiving of delays, so expectations need to be carefully handled. If it becomes clear once treatment has started that the anticipated completion date will not be met, then the patient needs to be advised as soon as possible. It is better for the patient to know well in advance than to be disappointed about this when treatment is nearing completion.
The reason for this is that, as the anticipated date of completion approaches, the patient’s level of expectation and sensitivity regarding fault finding can become more acute. It is better not to provide any more opportunities for dissatisfaction creeping in at this point. The whole essence of cosmetic treatment is in the eye of the beholder and a patient who is unhappy about an unexpected delay when approaching the final furlong may express their dissatisfaction by finding fault with the technical result. Following this, they then start to seek reasons for justifying a discount.
It is obviously better to avoid this risk by adjusting the finishing date early on. Better still, remember the old adage of under-promising and over-delivering. It always makes sense to build in some slippage time when providing information on how long or how many visits a course of treatment will take. Patients will not complain if their cosmetic aspirations are met before they were expecting it.
Providing cosmetic treatment carries an increased risk of a ‘disappointment gap’. To help reduce this, it is important from the very outset that both patient and dentist have a shared understanding of what a successful outcome will look like, in both senses of the word.

Some take-home points:

  • unrealistic expectations are often not identified or managed at an early stage;
  • many complaints and claims arise from patients feeling that their expectations were not met;
  • if there is any doubt at all about what is expected, it is wise to hold off on providing treatment; and,
  • it is much better to be dealing with a patient unhappy with you for not providing cosmetic treatment than one unhappy that you have.

Martin Foster

Dr Martin Foster BDS MPH DipHSM

Martin is Dentolegal Consultant at Dental Protection