Losing control – how far can autonomy take us?

Patient autonomy is a pillar of the consent process, but does it ever become problematic? Dr Annalene Weston, Dentolegal Consultant at Dental Protection, considers this in the context of a recent case.

The generation of patients imbued with the mantra of “doctor knows best” are still present in contemporary practice. However, the social movements cultivated and grown by the “flower power” generations of the 60s and 70s were a catalyst for widespread global social change. Following this, the tension between paternalism and autonomy finally gave way, and by the mid-80s patient rights were the winner. This means that we predominantly treat autonomous patients. Patients who are empowered to question us, who can choose and refuse our care, and even review us, and not always kindly. 

While paternalism may occasionally feel appealing, as it would seem like a much easier way to practise trouble-free dentistry, there can be no doubt that patient autonomy deserves its place as a cornerstone of medical ethics and critical component of patient care.

However, does autonomy ever go too far? And are we ever at risk of the tail wagging the dog?

Case study

Miss S was unhappy with her smile. She attended a specialist orthodontist for an assessment and was advised surgery would be essential for her to achieve an ideal outcome. However, she could consider a two-year course of fixed orthodontics if she was willing to accept a compromised camouflaged outcome. Unhappy with both these options, Miss S sought an appointment with Dr Z, a GDP who advertised aligner treatments. She expressed that she understood that she needed complex care, but reassured Dr Z that she was not looking for ‘perfect’; she was just looking for ‘better’. And, as her wedding was rapidly approaching, couldn’t he consider providing her with something quick and easy to help?

Despite his reservations, Dr Z agreed to take records and assess what, if anything, he could do. Dr Z proceeded as far as a ClinCheck, and at that stage his reservations outweighed his desire to please. He called Miss S and advised her that he couldn’t proceed, as he could not achieve an acceptable outcome for her. Miss S bombarded Dr Z with impassioned pleas, by email and by text. Surely he would help! She understood the risks and limitations – wasn’t it her money, her mouth and therefore her choice? 

Dr Z agreed to one more consultation to show her the ClinCheck and outline his concerns. Miss S reviewed the proposed treatment and proclaimed it to be everything she wanted. She paid the full fee in advance on leaving the surgery and scheduled all her appointments. Surely, Dr Z couldn't say no now, could he?

Difficult as it may have been to decline to treat Miss S, Dr Z very quickly began to wish he had stood his ground. While the treatment progressed as anticipated from the ClinCheck, the outcome did not meet Miss S’s expectations. She became difficult to manage and rude to the staff. Dr Z was pleased to reach retention so this nightmare could be over. Regretfully, although perhaps not unexpectedly, Miss S was unaccepting of her outcome, demanding a refund. 

Dr Z had barely had time to consider how he felt about this request when a letter from AHPRA arrived. The notification was accompanied by an expert report from an orthodontist setting out why the aligner treatment wouldn't work in the presence of a gross-skeletal discrepancy, and a complaint from Miss S, alleging to have been unaware of this fact and accusing Dr Z of “misleading her for profit”, soon arrived. 

Dr Z is not alone in his plight. Patients attend daily demanding specific treatments, researched on Google with a preconceived endpoint and price point. The critical point remains, however, that just because someone wants a specific treatment, it doesn't mean that you have to provide it to them, particularly if – like Dr Z – you are uncomfortable because you do not believe the treatment will be successful, or in the patient's best interests. Fortunately for Dr Z, his records accurately reflected the conversations that had been had, and critically those indicating Miss S's understanding and acceptance of the treatment and its limitations. AHPRA dismissed the matter.

Learning points

Patient autonomy is one of the four underpinning principles of medical ethics and a vital component of patient consent.

This does not, however, mean that the patient is in the driver’s seat – dictating the nature and type of their treatment, and controlling all decisions.

It is important that practitioners are not bullied or coerced into providing treatment they do not wish to – regardless of whether they are uncomfortable because they are out of scope, because they do not believe it to be in the patient's best interests or for any other reason.

The documentation of conversations we have with our patients in their clinical notes is a vital component – both of patient care and, when required, practitioner defence.