This study was an online questionnaire-based survey that aimed to explore the scenarios of ethical dilemmas during the clinical practice among orthodontists practicing in Saudi Arabia. Ethical judgement involves moral principles in determining whether the decision is right or wrong under the given circumstances. The five scenarios presented in this study represent some of the situations faced by clinicians in their regular practice. From the variation in the responses obtained, we can infer that judging right or wrong from the moral point of view is not an easy task and requires a deep-thinking process taking into consideration the overall circumstances around the patient.
The response rate was 28.46% in our study, and it was quite low compared to the 55% average response rate to the online dental questionnaire. The response rate exploring ethical dilemma among dental practitioners were 39% in a study by Porter et al. in Australia [7], and 96.5% by Dhanappa et al. in India [11]. A few similar studies did not mention the response rate in their manuscript [8, 12]. The in-person interview would probably receive responses but we selected the online mode of data collecting citing its convenience and economy [13]. The reduced response rate might be due to the busy schedule of the practicing orthodontist. Among those who responded, only 6 shared situations of ethical dilemma they faced which represent some of the scenarios often faced in Saudi Arabia. However, due to the limited sample size, this cannot be generalized to the whole orthodontists in Saudi Arabia.
In the first scenario, most of the participants (76%) favoured hearing the opinion of the previous practitioner before expressing their own. Patients seek a second consultation for multiple reasons such as dissatisfaction with the treatment approach, and doubt about the management plan. For the second practitioner, it might be sometimes difficult to convince the patient and parents if the proposed plan differs from whatever was suggested before in the previous consultation. In orthodontics, there is a wide variation in opinion among clinicians regarding single-phase or two-phase treatment. Besides, there can be different appliances for the same purpose. This might be the probable reason why most of the participants preferred to listen to the previous consultant’s opinion before stating their own. If their opinions align with the previous consultation, most of the participants (34) preferred to let the patient decide where to treat. This aligns with the principle of autonomy where the patient has the freedom to decide what is right for them and with whom to get treated [14]. The economic capacity of the patient for the recommended treatment is another factor for dilemma among the practitioners. Some of the participants in this study (12) would like to withhold the phase I treatment and wait for the single-phase fixed orthodontic treatment. As there is a wide controversy regarding early treatment in the orthodontic community, it is not surprising to have a such response among the study participants [15].
Extraction of premolars is widely practiced in orthodontics in cases of moderate to severe space requirements [16]. While there are separate indications for the extraction of the first and second premolars, they are not mutually exclusive and thus most cases can be managed with the extraction of either bicuspids depending upon the clinician’s preference. Most orthodontists rely on general practitioners for extractions and there are chances of extraction of tooth other than recommended especially in cases of premolars. In this study, most participants (28) preferred to tell the truth when the general practitioner extracted the wrong tooth. Most of their decision did not change regardless of their relationship with him/her.
It is quite common for an orthodontist to receive patients during mid-treatment because patients or orthodontists may move from one place to another. The situation of ethical dilemma arises when one notices something wrong going on in the treatment. In our study, most of the participants mentioned that they would express their views to the patient/parents regarding overall treatment if they noticed some deviation from the standard of care. However, one should be careful not to make any offensive remarks to the prior clinician and show professional superiority [17]. The aim should be just to inform the situation in the best interest of the patient. Besides, orthodontic treatment involves an esthetic component, and the assessment of beauty is subjective, and thus personal standards should be used as a criterion for such judgement.
Another situation of dilemma arises when the appropriate fees are not received from the patient. While it is ethically justifiable to charge for the treatment and ask for payment before the treatment [18], the scenario in orthodontics is a little different. In our study, 22 participants did not feel it to be ethical to withhold the treatment just because of an outstanding balance. According to the Michigan Dental Association, any dental treatment can be discontinued if the patient fails to pay the installments as agreed before but the clinician should provide the reason in written form indicating the date of termination of the service and the possible consequence of this [19].
Orthodontists sometimes encounter unusual requests from patients. Patients may demand orthodontic treatment which does not correlate with the treatment needs. Most of the participants said that they would deny orthodontic treatment if they did not feel its need based on the examination findings. One of the principles of medical ethics is nonmaleficence which says do no harm [20]. When there are no perceived benefits from orthodontic treatment, initiating the treatment just poses the risk of complications from the treatment. In a similar survey by Porter and Grey in Australia, most of the dentists responded that they could deny inferior quality treatment even if the patient accepts it when a better treatment option is easily available [7].
According to the participants from this study, who are from Saudi Arabia, the median probability of getting a similar scenario ranged from 3 to 3.5. The scenarios presented here are adapted from the problems listed by Jerrold in 1998. Due to the cultural and geographical variation, the nature of the situations that an orthodontist might encounter differs across the globe. Hence it is important to identify scenarios in our local context and discuss them among the orthodontists to better understand and respond to it adhering to the basic principles of medical and dental ethics. Although only a few participants shared situations of ethical dilemma they faced during their practice, we can start a discussion on these issues assuming that consultants across the country are more likely to encounter similar scenarios.
This was a pilot study conducted to explore the situations of ethical dilemmas among the orthodontists practicing in Saudi Arabia with a smaller sample size, and we could not cover practitioners across the whole country. On the other hand, the response rate was lower. However, this study can be a starting point for going deeper into the ethical issues that orthodontists are facing in their routine practice.