Ethical dilemma awaits dentists when patients refuse radiographs, other treatment

The ADA’s Principles of Ethics and Code of Professional Conduct (Code) require dentists to respect the patient’s rights to self-determination and confidentiality. Section 1 – Principle: Patient Autonomy of the Code “expresses the concept that professionals have a duty to treat the patient according to the patient’s desires, within the bounds of accepted treatment, and to protect the patient’s confidentiality. Under this principle, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s needs, desires and abilities, and safeguarding the patient’s privacy.” This principle applies whether the dentist is practicing as an employee, supervisor or owner and regardless of the practice setting.

While the patient generally has the right to dictate the terms of his or her care, they are not capable of legally consenting to substandard treatment. Therefore, dentists should proceed with caution when a patient refuses care the dentist determines is clinically necessary because practicing under the standard of care can lead to malpractice claims and disciplinary actions by the Ohio State Dental Board.

For example, dentists often ask what their responsibility is when treating a patient who refuses to have radiographs taken. Dental radiographs provide information critical to the identification and treatment of oral health problems because that is the only reliable way to view the bone, roots, attachments, interproximal areas, and under and around restorations. Despite the significant benefit of such images, however, some patients refuse to have radiographs taken because they perceive a risk of injury from radiation exposure. Other patients refuse based on the cost. While the patient can always refuse any treatment or procedure, regardless of the reason, the dentist is still obligated to proceed in a manner consistent with the standard of care.

Dental X-rays are not always necessary to provide proper treatment. National guidelines call for dentists to consider individual patient characteristics to judge their risks of decay and other dental problems before conducting a radiographic examination, and recommend that dentists do so only when there is an expectation that the additional diagnostic information will affect patient care. The dentist, knowing the patient’s health history and vulnerability to oral disease, is in the best position to make this judgment in the interest of each patient.

If the dentist determines based on clinical judgment that radiographs are needed for proper diagnosis, he or she should explain to the patient the importance of such images and the consequences of not obtaining them. If the patient continues to refuse the radiographic examination, the dentist may properly decline to treat the patient. Under these circumstances, termination of the dentist-patient relationship presents the least risk to the dentist because failing to take dental radiographs when needed for proper diagnosis qualifies as substandard care. This is so even if the patient signs a form stating refusal of radiographs as a personal preference and understands that the dentist cannot provide proper treatment because the dentist still has a legal and ethical duty to treat within the standard of care. If termination is the preferred option, elaborate documentation in the patient’s record is recommended. A dismissal letter should also be sent by certified mail to the patient emphasizing failure to treat some dental conditions may result in permanent, irreversible damage to the patient’s dental health.

If for any reason termination is not the preferred option, the best thing that can be done is to implement procedures that minimize the risk of liability or litigation and maximize the chance of success if litigation occurs. Such procedures include having the patient sign an “informed refusal” form acknowledging that the dentist explained the consequences of declining the procedure and the patient had all questions answered but still refused to follow the recommended diagnostic treatment. It is also recommended that the dentist provide the patient with documentation explaining the risks and benefits of radiographs, keep copies of that documentation in the patient’s record, and write a detailed note of the discussion had with the patient in the patient’s chart.

These principles generally apply regardless of the type of recommended treatment being declined. Following these procedures will provide evidence against a later claim that the patient did not know of or understand the recommendation. While this type of record or disclaimer is not absolute protection against litigation, it will ultimately demonstrate to the trier of fact what the recommendations of the dentist were and that the dentist cared enough for the patient to take the time to explain the potential adverse consequences of the patient refusing the treatment, and it will raise in the mind of the trier of fact that the patient may have contributed, by individual choice, to the negative outcome. For additional information on this issue, please contact the ODA legal department at (800) 282-1526 or consult with an attorney.