It has been accurately said that there are often many different ways to treat a patient properly. However, just because there are multiple ways of treating a patient well does not mean that every way of treating a patient is correct. While this seems simple and self-evident when stated this way, in practicality this concept is currently very much in question in orthodontics. Examples that quickly come to mind are orthodontic treatment for obstructive sleep apnea (OSA), expanders on 3-year-old children, and cone beam computed tomography on children of similarly young ages.
I believe that some consideration of the art and science of our profession and how this relates to the concept of moral relativism will help to shed light on when a treatment is ethical, when we should be respectful of a treatment that is different than our own, and when a treatment is unethical and should be pointed out as such.
To start, the course we go through in the diagnosis and treatment of a patient can be analogous to a line on a graph. This line may be straight or take many twists and turns as may be needed to properly treat a patient. Also, the line is continuous just as a patient’s treatment is continuous between the start and ending points.
Within this same analogy, the facts established by valid scientific research might be thought of as points on this graph. These points of valid scientific research have gaps between them and are unfortunately not continuous. The problem here is that we must continuously treat a patient from start to finish or by analogy draw a line on the graph, yet science can only provide individual points on the graph. So continuously treating a patient with only completely known scientifically proven principles or points is not possible.
As might be obvious by now in this analogy, while the points on our graph are the “science” in our treatment, the line between those points is the “art,” filling in where needed to allow continuous treatment to take place. Importantly, however, proper treatment demands that the line of our treatment crosses the points of science whenever this is possible. The science is mandatory and of higher priority. Art is only to fill in the gaps between the scientific points and is of lower priority.
Herein lays the explanation as to how multiple different treatments may be proper. If we plot the points of science on our graph, there are potentially an infinite number of different lines of treatment that cross all of the appropriate points of science and still share the same end point. All of these roads lead to Rome: ethical treatment. As such, treatments that are different from our own yet still account for and cross over the points of science deserve our respect. They also deserve our attention, as we may find a better treatment line than our own.
Also in this analogy is the explanation as to why certain treatments are improper or even unethical. Lines that represent these treatments do not cross over valid scientific points when appropriate. Worse, those supporting these treatments will sometimes create false scientific points along their line and then claim to have crossed them. As an example, orthodontic articles lacking legitimate scientific research methodology have been published in nonorthodontic sleep medicine journals. These are presented in lectures as valid scientific research. This false evidence is then used to justify improper and sometimes unethical treatments.
Examples of points of valid scientific evidence would be the American Association of Orthodontists (AAO) white paper and scientific articles published in nonpredatory peer-reviewed orthodontic journals showing that expansion is not a legitimate technique for treating OSA outside of the very rare direct recommendation of a physician board certified in sleep medicine, that we cannot prevent OSA with any known early childhood orthodontic treatment, and that extractions do not cause OSA. The logical conclusion of this is that, with the possible exception of severe craniofacial anomalies or syndromes, expansion should almost never be done on children under 7, expansion for treatment or prevention of OSA is nearly never indicated, and extractions do not cause OSA.
When those who do lecture on and practice these nonscientifically based treatments are questioned, the retort invariably becomes that all treatments and all beliefs are legitimate, and we need to be respectful of those treatments, those who treat that way, and those who teach others to treat that way. In their minds, every treatment deserves equal consideration and respect. This seems especially so if the treatment is one that they are doing or lecture on.
This is where the concept of moral relativism comes in. Moral relativism holds that no one opinion is objectively right, wrong, or superior to another. The philosophy has a natural appeal and was popular in the 1960s hippie culture in the form of “I’m okay. You’re okay.” While this superficially appeared to work in the peace and love culture of the ’60s, Moral relativism has a fatal flaw and a dirty underbelly. In fact, there are bad things and opinions in the world along with people who would willingly and intentionally harm others. These harmful things, opinions, and people cannot and should not have equal standing in a moral world. This gives us as orthodontists a moral obligation to point out the deficits of these harmful treatments and suppress the advocates for them as much as we are able.
As an extreme example, imagine if bloodletting were advocated by lecturing orthodontists as a means of treating and preventing OSA, advantageous to 3-year-olds, and facilitated achieving harmonious development of the jaws. Just as is happening with current improper treatments, these lecturing orthodontists would tell us how they have successfully treated patients this way for decades. Many case studies and slides of successful results would doubtless be presented. Were we to consider all treatments, opinions, and teachers as being equal, we would have to accept bloodletting as a legitimate orthodontic treatment. Moreover, we might even have to listen to them at AAO-endorsed lectures as a part of “hearing all sides of an issue.” Once having lectured there and placed this on their resume, they may easily use this experience to gain more speaking engagements lecturing on the many benefits of bloodletting.
As ridiculous and extreme as that example sounds, it is not completely unlike what is currently occurring in orthodontics. We would do well to remember that rather than being a fringe practice, bloodletting persisted as a legitimate means of medical treatment for over 2000 years. Doctors practiced it their entire careers, were convinced of its efficacy, and had many success stories. The practice lasted well into the late 19th century, when scientific studies were finally used to discredit it.
Our patients will be better treated, and we will be better clinicians if, instead of repeating medicine’s mistake, we learn from this example and accept what science has already taught us. The AAO white paper and the best science we have say that these treatments do not help patients, sometimes hurt patients, and, worse, are sometimes being done on 3-year-old children.
For those representing us, knowingly hosting a lecturer who uses poor science and teaches improper treatment is not just “hearing both sides.” It is a de facto endorsement of that treatment and lecturer. It helps the spread of these teachings elsewhere. This encourages even more improper treatment. As a result, allowing lecturers of this nature at AAO and regional orthodontic meetings should stop.
For the rest of us, we should not let improper treatment and those promoting improper treatment hide behind the false cover of moral relativism. We might help by professionally pointing out, or at least supporting those who professionally point out, these improper treatments and those lecturing for them. In this situation, we are not being disrespectful of another opinion. Rather we are actually acting morally by attempting to prevent improper treatment and promoting what is best for our patients. That seems very respectful, moral, and worthwhile.