Ethical dilemmas concerning orthodontic treatment among orthodontists in a sample from Saudi Arabia: a pilot study

Abstract

Background

Ethics is based on moral principles that should be the foundation for every healthcare decision, however, ethical concepts can often be challenging to define in specific clinical scenarios. There are several instances where a practising clinician often finds it difficult to make a proper decision despite maintaining integrity and professionalism. The objective of the present study was to explore the ethical dilemma faced by orthodontists practicing in Saudi Arabia concerning orthodontic treatment.

Method

This was a questionnaire-based cross-sectional study that was adapted from the scenarios of ethical dilemmas presented by Jerrold in 1998. Ten orthodontists from each province of Saudi Arabia were requested to participate in this study and the questionnaire were sent through email and their responses were analysed.

Results

A total of 37 responses were obtained (out of 130) with a response rate of 28.46%. Among them 23 were female and 14 were male. Most participants belonged to the age group 30–39 years and most of them have clinical experience of more than 5 years. There was a wide variation in the responses among the participants in all the scenarios presented. The median likelihood of getting similar scenarios in their clinical practice in Saudi Arabia ranged from 3 to 3.5.

Conclusion

There was a wide variation in the opinion among the practising orthodontists in Saudi Arabia in the scenarios presented. The presented scenarios are less likely to be perceived in the local context and some new situations of ethical dilemmas are identified.

Background

Medical ethics encompasses a collection of ethical concepts that serve as a guiding framework for healthcare practitioners in the provision of patient care [1]. The provision of ethical guidelines serves to establish a framework for distinguishing between right and wrong, so influencing the conduct of healthcare professionals in their interactions with patients and colleagues. Ethics encompass the societal adoption of moral principles, distinct from the legal framework that comprises a collection of laws and regulations established by a formal body vested with enforcement capabilities [2]. Each professional society typically establishes a code of ethics that serves as a guiding framework for its members, ensuring that they engage in their commercial activities with honesty and uphold professional integrity when interacting with consumers. Numerous dental organizations of a professional nature have established their code of conduct, principally grounded in the five fundamental principles: patient autonomy, nonmaleficence, beneficence, fairness, and veracity [2].

During clinical practice, dental professionals encounter ethical dilemmas of varying complexity and compliance issues that challenge them to determine the best option for their patient [3, 4]. Discussions about these ethical challenges often occur at at different professional meetings and social gatherings, aiming to identify the best way to handle these situations [5]. In recent years, the number of incidences of malpractice, negligence, etc. has increased along with the demand for quality care by dental professionals [6]. Consequently, ethical issues have received greater emphasis among professionals with the sharing of their experiences of ethical dilemmas encountered.

The elective nature of orthodontic procedures and the variety of possible options for treating a case often create situations of ethical dilemmas for orthodontists [7]. The introduction of newer treatment modalities with a claim of superior treatment results often confuses clinicians in deciding whether or not to adopt the new modality with short-term evidence. Besides, differences in philosophies within orthodontic professionals regarding early vs. late treatment, extraction vs. non-extraction, etc. add further to the dilemma in decision-making during treatment planning. Ethical dilemmas may arise during interdisciplinary consultations when specialists have differing opinions on the best approach for managing a patient’s condition [8]. Differences between the need and the desire of the patient really place an orthodontist in a difficult situation whether to address the concern of the patient or the real need perceived from the diagnostic evaluation [9]. Religious, and cultural beliefs can sometimes affect the use of different orthodontic materials leading to difficulties during orthodontic treatment [10].

The scenario of ethical dilemmas in dentistry can be found worldwide. A survey conducted among 499 dentists in Australia revealed that poor quality of treatment presented was the most frequently encountered situation of dilemma followed by requests for fraudulent receipts [11]. The ethical challenges faced by dentists in India include issues in waste management in dental clinics, sterilization, lack of competency among dentists, the rising cost of procedures, inadequate informed consent process, advertising, lack of agreement among dental professionals regarding treatment options, poor record management, etc [12]. Similarly, a study on dental practitioners in Saudi Arabia found them in a situation of an ethical dilemma when they encounter substandard care from other dentists, and criticism and unprofessional behaviour from colleagues [12]. They further realized the need for continuing education on this topic to handle the situation more efficiently. In the nation of Saudi Arabia, healthcare professionals, including orthodontists, are sourced from diverse countries, resulting in a range of cultural and socioeconomic backgrounds. Consequently, these practitioners are more likely to confront ethical dilemmas during the course of treatment. The existing body of research does not contain any studies that have specifically investigated the ethical difficulties encountered by orthodontists practicing within the context of Saudi Arabia. Therefore, the primary objective of this study is to investigate the ethical quandary surrounding orthodontic therapy as perceived by orthodontists practicing in Saudi Arabia.

Method

The present investigation was conducted as a descriptive cross-sectional study spanning the period from April 2023 to July 2023. The target population for our study included all orthodontists, including foreign nationals, who are currently engaged in the practice of orthodontics in Saudi Arabia and are registered members of the Saudi Orthodontic Society. This study involved the convenient selection of ten orthodontists from each of the thirteen provinces in Saudi Arabia. The study gained ethical clearance from the Research Ethics Standing Committee at the University of Hail (No: H-2023-012). Additionally, authorization to utilize the scenario in the questionnaire [13] was acquired from the original publisher, Elsevier. All participants provided informed consent prior to their inclusion in the study.

The survey was designed using the Google Forms and distributed to potential participants through email, with a request for their involvement. A follow-up email was sent as a reminder in the event that no answer was received within a two-week period subsequent to the initial email. Subsequent to the aforementioned exchange, no other electronic mail communication ensued. The design of the questionnaire was inspired by the orthodontic scenario described by Jerrold in 1998 [13]. The assessment encompassed five distinct orthodontic scenarios, which were thereafter accompanied by a series of inquiries aimed at examining ethical predicaments. Participants were thereafter requested to provide ratings, using a Likert Scale ranging from 1 to 10, indicating the likelihood of their personal experience aligning with a comparable event in their professional practice. Ultimately, we requested the participants to disclose any instances of ethical quandaries encountered within the context of their orthodontic profession.

The data from the google form was exported in the Excel Sheet and this was subsequently analysed to explore the ethical dilemmas faced by orthodontists. Descriptive statistics were used to analyse the demographic information and responses to the various scenarios.

Results

A total of 130 orthodontists, with 10 representatives from each of the 13 provinces in Saudi Arabia, were contacted by email for the purpose of this study. The number of responses received was 37, resulting in a response rate of 28.46%. Within the sample population, there were 23 female respondents and 14 male respondents. The majority of the participants fell within the age range of 30–39 years, and a significant proportion of them possessed clinical experience exceeding 5 years. A total of twenty individuals were employed in the public sector, specifically in government positions (Table 1).

Regarding the first scenario, most of the participants (28, 76%) believed that it was ethical to hear previous practitioners’ opinions before expressing their own opinions. Almost 92% of them believed that patients should be given a choice in selecting their doctor for the orthodontic treatment after the consultation appointment. Twenty-five orthodontists would prefer to prescribe the lingual holding arch as per the actual need of the patient, however, 12 (32%) of them would consider the financial aspect of the LHA and preferred single-phase fixed orthodontic treatment (Table 2).

For the second scenario, 28 (76%) participants were in favor of informing the patient regarding the error made in the extraction by the general dentist and 32 (87%) of them remained adhered to their decision regardless of the relationship with the general dentist (Table 2).

Regarding the third scenario, most of the participants (21, 57%) did not want to add their views on the overall treatment that was started by somebody else and just favored addressing the acute problems that led patients to visit them. Twenty (54%) of them did not find any obligation to reveal any problems in the overall treatment progress to their professional society, however, their decision might change if they encounter similar conditions frequently. The participants had mixed opinions when the treating clinician was a specialist or general practitioner where nearly half (19) of them did not change their decision based on the qualification of the clinician. Eighteen (49%) of them would like to report the problem, if at all, to the patients or the guardians rather than friends or other professional societies (Table 2).

The fourth scenario discussed the continuation of the orthodontic treatment despite failure in the payment and 22 (60%) participants found it to be unethical to hold the treatment just because of the delay in clearing the orthodontic charges. In the fifth scenario, 33 out of 37 (90%) participants felt it was unethical to begin the treatment for other advantages against the actual health needs (Table 2).

The participants were further asked about the possibility of having similar ethical dilemmas as shown in the five scenarios. The median score for the probability of encountering situations similar to scenarios 1,2 and 5 was 3 whereas for scenarios 3 and 4, the median score was 3.5 (Table 2).

Only 6 (16%) of the participating orthodontists shared some situations of ethical dilemma they experienced during their clinical practice (Table 3).

Table 1 Demographic features of the participants

Table 2 Responses to the different scenarios (expressed in number)

Table 3 Different situations of ethical dilemmas experienced by participants

Discussion

This study utilised an online questionnaire 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 reflect common situations faced by clinicians in their regular practice. The variation in the responses suggests that making moral judgement is complex and requires a deep-thinking process taking into consideration the overall circumstances surrounding each 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 [11], and 96.5% by Dhanappa et al. in India [14]. A few similar studies did not mention the response rate in their manuscript [12, 15]. Although in-person interviews might have yielded higher response rates, we opted for the online survey due to its convenience and cost-effectiveness [16]. The low response rate might be attributed to the busy schedules 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 all 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 what 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 [17]. 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 [18].

Extraction of premolars is widely practiced in orthodontics in cases of moderate to severe space requirements [19]. 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 [20]. 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 [21], 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 instalments 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 [22].

Orthodontists sometimes face unusual requests from patients. Patients may demand orthodontic treatment that do not align with the treatment needs. Most of the participants said that they would deny orthodontic treatment if it wasn’t justified based on the examination findings. One of the principles of medical ethics is nonmaleficence which says do no harm [23]. 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 [11].

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. Few scenarios shared by the participants are similar to the ones that are administered in this research. 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 pilot study aimed to explore the situations of ethical dilemmas among the orthodontists practicing in Saudi Arabia with a smaller sample size, and we could not cover enough practitioners across the whole country. Despite the lower response rate, this study serves as a preliminary investigation and provides a foundation for further research into the ethical issues faced by orthodontists in their routine practice.

Conclusions

Different scenarios posed situations of ethical dilemma among the practicing orthodontists and their opinions varied on the further steps of management. The scenarios presented here are less likely to be faced in Saudi Arabia and a few situations faced in local scenario has been identified. Further exploration of possible situations and discussion among clinicians will help in making fair decision in clinical practice in local scenario.