At first sight one might say that adjusting the denture is a good solution for the family. Both the father and the daughter have a new denture. So, why bother…  Indeed, if the patient had not asked the dentist for help, there would not have been a case.  It is precisely his getting involved that raises both legal and ethical questions.

From a legal point of view the dentist has to follow the standard of care. In order to determine whether the dentist has followed this standard, a judge has to call in an expert witness, which most often is a local dentist. It is highly unlikely the expert will deem the adjustment of the denture to meet the standard of care. This is because most capable dentists will refuse to adjust a secondhand denture.

Though most dentists will refuse to adjust the denture this does not mean that adjusting the denture is not an acceptable solution for the patient. The first ethical principle at stake is "do good" (principle of beneficence). By adjusting the denture the dentist will relieve the patient of her pain caused by the sore spot (if it is indeed the case that the denture, once adjusted, will fit reasonably well and the occlusion is acceptable).

Secondly, health care should be effective and efficient. One could argue that adjusting the denture leads to a quicker solution of her edentulousness, compared to making a new prosthesis. Another argument that the adjustment is beneficent to the patient is that this could be more cost-effective.

Finally, a health provider should take the wishes of the patient into account. The adjustment of the prosthesis is clearly a wish of the patient.

In conclusion: the requested adjustments appear to be beneficial to the patient from an ethical and a cost-effectiveness point of view. However, in most jurisdictions the adjustment of the denture will not meet the standard of care and the dentist, hence, could face legal sanctions if he proceeds.

Rutger Sonneveld & Wolter Brands
Department of Community Dentistry
Radboud University Medical Centre
PO Box 9101
6500 HB Nijmegen, The Netherlands
Tel: +31 (0)24 – 3616410 / Fax: +31 (0)24 - 3540265
r.sonneveld@dent.umcn.nl

Commentary 3

This sad report of two patients’ dental health raises ethical questions at multiple levels. Can a society, over the long term, consider itself wholesome when access to fundamental health services are denied to a portion of its population, as appears to be the situation in this health record? What are, and how does one resolve, the dilemmas attendant to fundamental failures of distributive justice? What are the ethical lessons and admonitions that fall upon those of us who are empowered in the acquisition, and in the delivery, of dental services – specifically prosthodontic services? What are the responsibilities of individual members of society?

In regard to access to care, the stereotypical capitalist first reading of this health record would hold the patient, a truck driver who likely had gained a modest to moderately high income through his working life, responsible for the state of his oral health. The stereotypical socialist first reading of this health record would hold the truck driver and his daughter to be victims of an ill-directed fee-for-service healthcare system, citing access to care as the principle concern. The health record, as presented, offers insufficient information to permit either conclusion.

The record permits us to know that the truck driver’s old removable partial denture was ill-fitting, and has been ill-fitting for some time. It does not permit us to know the reason(s) why the old prosthesis had been allowed to reach this undesirable state. Though prosthodontic wisdom offers certainty that the old prosthesis cannot fulfill any of the professional criteria for success, the record permits us no insights into the truck driver’s daughter’s socioeconomic state and no insights into her perspective on the success of her second-hand prosthesis.

In regard to distributive justice, the daughter – almost certainly an adult – appears to lack resources necessary to the acquisition of prosthodontic services, potentially a victim of distributive injustice. As distributive injustice exists, it serves as evidence of societal ill, thus the injustice demands rectification.

Regarding the ethical lessons and admonitions that fall upon those of us who are empowered, as moral agents it is necessary for us to look beneath the application of formal ethical principles and abstract reasoning about their application, seeking to understand the myriad of factors unknown to us, the readers. Quotidian life – for the truck driver, his daughter, members of the dental profession with whom they interact, and those of us who now reflect upon the matter – is incomprehensibly complex. What factors led to the dental neglect of the two patients…economic suppression? inadequate distribution of dental services in the patients’ environment? inadequate education regarding dental health? thoughtful self-sacrifice by the daughter – herself a mother – in favor of the advancement of her children? a thoughtless, alcoholic dentist?…or any of numerous other factors?

One is drawn to the wisdom of Wendell Berry who, addressing another complex issue granted an insight that appears to this observer to have nearly universal application.

There are several…problems, and all of them are difficult. There would be more hope of solving them if they could be understood in such a way as to show the unlikelihood that the solutions can be simple – the unlikelihood, that is, that remedies can be thought up by the people at the top and bestowed or imposed upon the people lower down. (Berry Wl:The Hidden Wound. North Point Press, New York, 1989, p. 115).
 

Denny Smith
Winnipeg MB, Canada
dmsmith@mts.net