ETHICAL AND LEGAL GUIDELINES DECIDING ABOUT PATIENTS’ REQUESTS FOR EXTRACTION

Khairallah Moutaz

1. Agerholm D. Reasons for extraction by dental practitioners in England and Wales: a comparison with 1986 and variations between regions. J Dent 2001;29(4):237-241.

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4. Richards W, Ameen J, Coll AM, Higgs G. Reasons for tooth extraction in four general dental practices in South Wales. Br Dent J 2005; 198(5):275-278.

5. McCaul LK, Jenkins WM, Kay EJ. The reason for the extraction of various tooth types in Scotland: a 15-year follow up. J Dent 2001;29(6): 401-407.

6. Johnson TE. Factors contributing to dentists’ extraction decision in older adults. Spec Care Dentist 1993;13(5):195-199.

7. McCaul LK, Jenkins WM, Kay EJ. The reasons for extraction of permanent teeth in Scotland: a 15-year follow-up study. Br Dent J 2001;190(12):658-662.

OBJECTIVES

1. Legal and ethical principles relevant to the assessment of a request for extraction.

2. Describe cases in which psychological or emotional considerations appear to influence irrational request for extraction.

3. Discuss how to resolve these issues (cases).

DOCTORQUACK (WITCHDOCTOR)?????????????

WHAT IS BIOETHICS?

• Bioethics is about the study of ethical issues arising along health care or research, and the associated decision-making process to resolve them.

• When does an issue in practice be an ethical issue ?

1- WHEN THERE IS CONFLICT OF MORAL VALUES, AND BELIEFS BETWEEN THE HEALTH CARE PROVIDERS AND THE PATIENTS.

Blood transfusion to a severely bleeding patient refuses to take blood, even this refusal can lead to

severe life threat and eventually death.

2- When the issue in focus is related to justice in allocating the available

resources.A classical example is which of the cancer drugs should be funded publicly. Should we choose a drug which efficiently improves the quality of life of few patients? Or a drug that makes little improvement for a larger number of patients.

3- When there is conflict of commitments and responsibilities

At one hand, there is the commitment of the health care provider to preserve patients' lives, however there is the responsibility to "rationally" use the resources available to him/her on the other hand. The classical example of which is "one ICU bed, and Two patients: whom to choose?"

THREE QUESTIONS

• How to take an (and not the) ethically acceptable decision to the issue in focus?

• Why did we take this decision? (i.e. why we chose this ethical option and not another?)

• How to implement the decision we have taken?

• Clinical ethics: which is concerned with the ethical issues related to clinical practice in health care settings.

• Research Ethics is concerned with the protection of humans participating in research.

• Organizational ethics, which is concerned

more with fair allocation of health care resources.

ETHICAL PRINCIPLES IN CLINICAL PRACTICE (BEAUCHAMP & CHILDRESS 2009):

• Autonomy "self-rule" (Respect for persons): this refers to the person's right to make free decisions about his or her health care.

• Beneficence (Do Good)• Non-maleficence (Do No Harm)• Justice

A. FREE INFORMED CONSENT:

• "Without a consent, either written or oral, no surgery may be performed.

• It is the patient, not the doctor, who decides whether surgery will be performed, where it will be done, when it will be done and by whom it will be done."

-- Allan v. New Mount Sinai Hospital (1980) 28 O.R. 356

B. DISCLOSURE

• This refers to the process during which physicians provide information about a proposed medical investigation or treatment to the patient.

C. CAPACITY:

• Refers to the presence of a group/set of functional abilities, a person needs to possess in order to make a specific decisions (Griso and Applebaum, 1998). These include:

• To UNDERSTAND the relevant information• To APPRECIATE the relatively foreseeable

consequences of the various options available.

D. VOLUNTARINESS:

• Refers to a patient's right to make treatment decisions free of any undue influence.

Influences include:• Physical restraint or sedation.• The use of explicit or implicit threat to ensure

that the treatment is accepted.• Manipulation involves the deliberate distortion

or omission of information in an attempt to induce the patient to accept a treatment.

EXTRACTIONS

Caries Periodontal disease Severe trauma to the

teeth. Third molars. Orthodontic reasons.

Dentist:- Diagnosis - Inform adequatelyPatient:Giving consent to the proposed treatment.

2.4% TO 17%

Autonomy,What should the dentist do if the teeth in question actually are still sound?

It seems unethical simply to grant that request.

LEGAL VIEWPOINT SURROUNDING REQUESTS FOR EXTRACTION

1. Standard of care2. Informed consent from the patient

A dentist never can be obligated to breach the standard of care. This also is known as the “principle of professional autonomy.”

The interventions must conform to “the degree of care and skill that a dentist of the same medical specialty would use under similar circumstances.”

The way in which this standard of care is interpreted differs from country to country.

If recourse a dentist decision in a state that uses locality rule, the dentist’s interventions are evaluated in reference to the standards of the state or of the community.

It is important to keep in mind that these standards focus on dentists and their geographically determined habits.

RATIONALIRRATIONAL

25-year-old man, who comes to the oral surgeon with the request to remove all his teeth because he has dental care phobia. His dentition is completely sound.

The oral surgeon does not support the extraction.

Continues to insist an extractionThe dentist has provided extensive

information explaining that such an extraction would be harmful to him.

The dentist should be mindful if his patient has the capacity to make a decision about his own health care.

If the patient does not have the capacity to provide informed consent, his or her decision is not valid

Without a valid consent, the dentist can provide no treatment of any kind.

FIRST SCENARIO: A PATIENT WHOSE TEETH ARE IN SUCH BAD CONDITION THAT EXTRACTION IS THE ONLY REALISTIC OPTION.

Unlikely to result in major disagreements between dentists and

their patients.

SECOND SCENARIO: THE DENTIST PROPOSES TO RESTORE THE PATIENT’S TEETH, BUT THE PATIENT REFUSES AND REQUESTS EXTRACTION INSTEAD PROVIDING REASONS UNDERSTANDABLE (FINANCIAL HARDSHIP).

Informed the patient properly, the requirement of informed consent prohibits from treating the patient against his well.

Bide by the principle of beneficence: some dentists might offer the restorative treatment at a lower price or perhaps even free of charge.

The dentist should refuse to extract. The patient then has the option to have those teeth restored at a later date when personal finances so allow.

THIRD SCENARIO: A PATIENT WHOSE DENTITION DOES NOT DEMONSTRATE ANY MEDICAL NEED FOR EXTRACTION, BUT WHO REQUESTS AN EXTRACTION FOR CULTURAL REASONS.

Peoples of Sudan, it is tradition to have the follicles or teeth removed.

South African studies demonstrate that 41 % of teeth extraction were performed for cultural reasons, of which 93.7 percent were removals of the four maxillary incisors.

What should a dentist practicing do if a patient from such an ethnic or cultural group asks him or her to carry out this intervention.

The dentist is legally bound by the standard of care and not obliged to treat beyond the bounds of accepted treatment.

IRRATIONAL REQUESTS FOR EXTRACTION

The request is based not on rational considerations, but instead on fear or some other psychological condition.

The patient has the capacity to provide informed consent. Criteria for the capacity to consent include a determination that the patient understands basic information about the diagnosis, prognosis and the consequences of the proposed treatment.

Generally, when a patient lacks the capacity to provide informed consent for treatment, the consent must be provided by a surrogate who shall represent the interests of the patient.

PATIENT SEEMS TO HAVE THE CAPACITY TO PROVIDE INFORMED CONSENT, BUT THE EXTRACTION REQUEST ITSELF APPEARS IRRATIONAL?

This scenario may arise if the patient has an extreme Fear of dental treatment, a Post Traumatic Stress Disorder (PTSD), a somatoform pain disorder or a condition in which a disturbed perception of one’s own body is the focal point, such as Body Dysmorphic Disorder (BDD) or Body Integrity Identity Disorder (BIID).

FEAR OF DENTAL TREATMENT A 37-year-old man with a phobia of dental treatment that arose

after a traumatic experience during the extraction of a third molar. He has a number of carious teeth, and gingivitis. The restored teeth are in good condition.

After the third-molar extraction he began refusing any dental treatment and asked for a total extraction to be performed under general anesthesia.

The dentist did not consider total extraction to be indicated and, together with a psychologist, had many discussions with the patient about the subject.

The patient had no evidence of psychopathology. After considering these options for three months, the patient

persisted in his request. The dentist required him to sign a letter in which he stated that he

knew of no dental reason for the total extraction and that this was to take place at the specific request of the patient.

The dentist then performed the total extraction.

If a patient is found to have a specific phobia about dental treatment, he may lack the capacity to make decisions.

Some mental illnesses lead to a patient’s decreased capacity to consent requiring specialized psychiatric treatment.

A dentist should discuss with the patient the option of a referral to a mental clinician to treat the underlying phobic condition.

Dental-care phobia is a treatable condition with an excellent prognosis.

Most patients with this condition respond well to therapy

Forms of psychopathology in which fear is driven by traumatic experiences, not related to dental care.

PTSD, which can be caused by incest, abuse, rape (including oral rape) or torture.

PTSD manifests itself as a serious form of fear that frequently exceeds the patient’s emotional strength. Dental restorative treatment is impossible, the patient frequently views extraction under general anesthesia as the only solution.

Treatment of PTSD certainly requires the involvement of a mental health professional.

SOMATOFORM PAIN DISORDER 47-year-old woman, has undergone extensive dental

treatment during the course of several years because of pain that she experienced.

Most of her teeth have been restored and treated endodontically. In addition, she has undergone various apical resections and even, at her request, a few extractions by various dentists .

None of this, however, made any difference with regard to the pain that she continues to experience.

Now she is requesting urgently that her dentist remove her entire dentition, because she is certain that this will bring her pain to an end. The dentist cannot find any oral pathology that could explain the lingering pain.

Dentist should not carry out any dental intervention before investigating the possibility of a psychological component that might explain the pain.

The terms “somatic,” “somatoform” or “somatization” frequently are used by mental health professionals to describe a situation in which psychological stress is translated into physical complaints without there being any demonstrable physical disease process. If the resulting complaint is pain, this is called a “somatoform pain disorder.”

Extraction is unnecessary and ineffective intervention and could be viewed as

malpractice.

DISORDERS OF SELF-PERCEPTIONWho are extremely ashamed of their looks.This condition is known as

“dysmorphophobia” or BDD, Aspect of their appearance that their

concern is considered pathological.Patients with BDD frequently consult

plastic surgeons, dermatologists, orthodontists or dentists with the request that they remove or change the imagined defect.

Patients with one of these disorders have the feeling that their limbs do not belong to them.

Surgeon was reported to have treated patients with probable BIID by amputating the lower parts.

This case is analogous to the removal of healthy teeth. In this case even the patient had received adequate

information , one has to wonder, whether the patients had the capacity to consent to such leg amputations.

Dentist should consider referring the patient to a mental health professional before undertaking any dental intervention.

For patients with BIID, no effective therapy is known.

CONCLUSION

In most cases of patients’ requesting extractions, the Ethical principle of non maleficence will play a decisive role in the dentist’s decision making.

In cases in which the request appears influenced by a specific mental condition such as a phobia of dental treatment, extraction rarely is justifiable.