j COM M ENTARIES f
Editorials represent the opinions of the authors and not necessarily those of the American Dental Association.
GUEST EDITORIAL
The e th ic s o f m a n ag in g in c id e n ta l fin d in g s implications and challenges for the profession Arthur H. Friedlander, DMD; Charles N. Bertolami, DDS, DMedSc
n December 2013, the Presidential Commission for the Study of Bioethical Issues released a voluminous report entitled Anticipate and Com m u nicate: Ethical Management of Incidental and Secondary Findings in the Clinical, Research, and Direct-to-Consumer Contexts.1 The report identi fies specific criteria that practitioners can use to determine when it is ethi cally permissible or obligatory for them to disclose or not disclose to patients “anticipatable incidental findings”—findings that are known to be associated with the test used but lie outside its original purpose. The report is germane to dentists who obtain and interpret panoramic and cone-beam computed tomographic (CBCT) imaging studies that may lead to the discovery of such a finding. The identification of an incidental finding can be lifesaving,
I
It is both ethical and logical to discern ahead of time, through a standard informed consent process, the patient’s wishes regarding the extent of disclosure and the management of reasonably anticipatable findings. but it also can lead to distress if the patient had not been forewarned that incidental findings may arise. An example encountered in dentistry would be the identification of an asymptomatic, severely stenotic, calcified carotid artery atherom a requiring semiemergent surgery on a CBCT study obtained initially to identify satisfactory sites for implant placement.2 To fully address these ethical concerns, professional societies are encour aged to develop educational materials and guidelines that inform clinicians of anticipatable incidental findings, as well as determine which findings are sufficiently significant to become actively pursued secondary findings (for example, an atheroma observable on a panoramic radiograph) and how best to manage each. Once cognizant of these facts, clinicians are expected to acquire a written informed consent statement from the patient that identifies these possible findings before obtaining the image. The consent process is conceptualized as including a discussion about whether and how the patient wishes to be informed of any clinically significant findings that may require
910
JADA 145(9)
http://jada.ada.org
September 2014
| COMMENTARIES |
further study (with an acknowledg ment that this may be associated with additional risk and cost) or intervention (for an actionable inci dental finding) to ensure his or her health and well-being. If the patient declines to receive this information after the dentist has explained the potential ben efit, the dentist then may decline on ethical grounds to perform the test and refer the patient to another dental professional. If, however, the dentist understands and respects the patient’s decision, he or she ethi cally may agree to perform the test but not inform the patient of any incidental findings. A hypothetical example of this latter construct is a cognitively intact 80-year-old patient with advanced malignant disease who is referred for CBCT imaging of the jaws for osteonecrosis because of nonhealing tooth extraction sites that may be related to use of bisphosphonate, which is a component of his chemotherapeutic regimen. The patient informs the dentist that he is interested only in determining the cause of his jaw pain and does not want to be informed of any inciden tal findings. On review of the imag ing study, the dentist notes multiple osteolytic lesions in the skull and, consistent with the patient’s desires, does not relay this finding to him. As the power of diagnostic methodologies increases, many scenarios could develop that warrant prospective consideration of ethical dilemmas of the sort envisaged here. A particularly important example might be the emergence of broadbased salivary diagnostic tech niques.3 These techniques likely will screen for a wide array of both oral and systemic conditions, including those that fall beyond the original intent of the test. As the impact of the Commissions report begins to be
felt, practitioners will need to clarify for patients the difference between screening and diagnostic techniques and will need to consider possible scope-of-practice implications. The Commission’s specific recommendation to modify todays informed consent process by ensur ing the patient’s right not to know certain things represents a richer and more holistic understanding of a persons overall health. In its move ment toward a more patientcentered approach, the bioethics commission used four ethical prin ciples that are consistent with 21stcentury sensibilities of informed consent, framing them within a humanitarian understanding of well being.4 These principles—respect for persons; beneficence; justice and fairness; and intellectual freedom and responsibility—have special ap plicability to the ethical management of incidental or secondary findings. Thus, it is both ethical and logical to discern ahead of time, through a standard informed consent process, the patient’s wishes regarding the extent of disclosure and the manage ment of reasonably anticipatable findings. This does, however, leave the matter of how entirely unantici pated findings are to be handled, as well as how the massive data flow of new diagnostic methods might affect scope of practice in cases in which practitioners are profession ally competent to assess one segment of the data, but not all of the data in their entirety. The challenge now before the oral health professional is how best to comply, in a timely fashion, with the Commission’s recommenda tions. It is recognized, however, that individual clinicians may need guidance in implementing these sug gestions. Therefore, we propose that the American Dental Association
JADA 145(9)
convene a meeting with representa tives from the American Dental Education Association, the Academy of General Dentistry and dental specialty organizations, as well as dental-medical ethicists to develop a set of guidelines that will assist indi vidual clinicians in complying with the Commission’s recommendations. In summary, the bioethics commission recommends that all clinicians anticipate and plan for incidental findings and communi cate that plan to their patients. When dentists anticipate such possibilities and communicate with their patients in this shared decision-making process, incidental findings are likely to be managed in a manner that satisfactorily addresses both the pa tient’s desires and the commission’s recommendations. ■ doi:10.14219/jada.2014.38 Dr. Friedlander is a professor-in-residence, Oral & Maxillofacial Surgery, University of California-Los Angeles School of Dentistry, and the associate chief of staff/director of graduate medical education, VA Greater Los Angeles Healthcare System. Address correspondence to Dr. Friedlander at VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, Calif. 90073, e-mail arthur. [email protected]. Dr. Bertolami is the Herman Robert Fox Dean, New York University College of Den tistry, New York City. 1. Presidential Commission for the Study of Bioethical Issues. Anticipate and communi cate: ethical management of incidental and secondary findings in the clinical, research, and direct-to-consumer contexts. December 2013. http://bioethics.gov/sites/default/files/ FINALAnticipateCommunicate_PCSBI_o.pdf. Accessed June 15, 2014. 2. Almog DM, Padberg FT Jr, Carmel G, Friedlander AH. Previously unappreciated carotid artery stenosis diagnosed by cone beam computerized tomography. J Oral Maxillofac Surg 20i3;7i(4):702-705. 3. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes toward chairside screening for medical conditions. JADA 20io;i4i(i):52-62. 4. Bertolami CN. Moving ethics curricula forward. Ethics Biol Engineer Med 201152(2): 87-106.
http ://ja d a .a d a .o rg
Septem ber 2014
911
Copyright of Journal of the American Dental Association (JADA) is the property of American Dental Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editorials represent the opinions of the authors and not necessarily those of the American Dental Association.
GUEST EDITORIAL
The e th ic s o f m a n ag in g in c id e n ta l fin d in g s implications and challenges for the profession Arthur H. Friedlander, DMD; Charles N. Bertolami, DDS, DMedSc
n December 2013, the Presidential Commission for the Study of Bioethical Issues released a voluminous report entitled Anticipate and Com m u nicate: Ethical Management of Incidental and Secondary Findings in the Clinical, Research, and Direct-to-Consumer Contexts.1 The report identi fies specific criteria that practitioners can use to determine when it is ethi cally permissible or obligatory for them to disclose or not disclose to patients “anticipatable incidental findings”—findings that are known to be associated with the test used but lie outside its original purpose. The report is germane to dentists who obtain and interpret panoramic and cone-beam computed tomographic (CBCT) imaging studies that may lead to the discovery of such a finding. The identification of an incidental finding can be lifesaving,
I
It is both ethical and logical to discern ahead of time, through a standard informed consent process, the patient’s wishes regarding the extent of disclosure and the management of reasonably anticipatable findings. but it also can lead to distress if the patient had not been forewarned that incidental findings may arise. An example encountered in dentistry would be the identification of an asymptomatic, severely stenotic, calcified carotid artery atherom a requiring semiemergent surgery on a CBCT study obtained initially to identify satisfactory sites for implant placement.2 To fully address these ethical concerns, professional societies are encour aged to develop educational materials and guidelines that inform clinicians of anticipatable incidental findings, as well as determine which findings are sufficiently significant to become actively pursued secondary findings (for example, an atheroma observable on a panoramic radiograph) and how best to manage each. Once cognizant of these facts, clinicians are expected to acquire a written informed consent statement from the patient that identifies these possible findings before obtaining the image. The consent process is conceptualized as including a discussion about whether and how the patient wishes to be informed of any clinically significant findings that may require
910
JADA 145(9)
http://jada.ada.org
September 2014
| COMMENTARIES |
further study (with an acknowledg ment that this may be associated with additional risk and cost) or intervention (for an actionable inci dental finding) to ensure his or her health and well-being. If the patient declines to receive this information after the dentist has explained the potential ben efit, the dentist then may decline on ethical grounds to perform the test and refer the patient to another dental professional. If, however, the dentist understands and respects the patient’s decision, he or she ethi cally may agree to perform the test but not inform the patient of any incidental findings. A hypothetical example of this latter construct is a cognitively intact 80-year-old patient with advanced malignant disease who is referred for CBCT imaging of the jaws for osteonecrosis because of nonhealing tooth extraction sites that may be related to use of bisphosphonate, which is a component of his chemotherapeutic regimen. The patient informs the dentist that he is interested only in determining the cause of his jaw pain and does not want to be informed of any inciden tal findings. On review of the imag ing study, the dentist notes multiple osteolytic lesions in the skull and, consistent with the patient’s desires, does not relay this finding to him. As the power of diagnostic methodologies increases, many scenarios could develop that warrant prospective consideration of ethical dilemmas of the sort envisaged here. A particularly important example might be the emergence of broadbased salivary diagnostic tech niques.3 These techniques likely will screen for a wide array of both oral and systemic conditions, including those that fall beyond the original intent of the test. As the impact of the Commissions report begins to be
felt, practitioners will need to clarify for patients the difference between screening and diagnostic techniques and will need to consider possible scope-of-practice implications. The Commission’s specific recommendation to modify todays informed consent process by ensur ing the patient’s right not to know certain things represents a richer and more holistic understanding of a persons overall health. In its move ment toward a more patientcentered approach, the bioethics commission used four ethical prin ciples that are consistent with 21stcentury sensibilities of informed consent, framing them within a humanitarian understanding of well being.4 These principles—respect for persons; beneficence; justice and fairness; and intellectual freedom and responsibility—have special ap plicability to the ethical management of incidental or secondary findings. Thus, it is both ethical and logical to discern ahead of time, through a standard informed consent process, the patient’s wishes regarding the extent of disclosure and the manage ment of reasonably anticipatable findings. This does, however, leave the matter of how entirely unantici pated findings are to be handled, as well as how the massive data flow of new diagnostic methods might affect scope of practice in cases in which practitioners are profession ally competent to assess one segment of the data, but not all of the data in their entirety. The challenge now before the oral health professional is how best to comply, in a timely fashion, with the Commission’s recommenda tions. It is recognized, however, that individual clinicians may need guidance in implementing these sug gestions. Therefore, we propose that the American Dental Association
JADA 145(9)
convene a meeting with representa tives from the American Dental Education Association, the Academy of General Dentistry and dental specialty organizations, as well as dental-medical ethicists to develop a set of guidelines that will assist indi vidual clinicians in complying with the Commission’s recommendations. In summary, the bioethics commission recommends that all clinicians anticipate and plan for incidental findings and communi cate that plan to their patients. When dentists anticipate such possibilities and communicate with their patients in this shared decision-making process, incidental findings are likely to be managed in a manner that satisfactorily addresses both the pa tient’s desires and the commission’s recommendations. ■ doi:10.14219/jada.2014.38 Dr. Friedlander is a professor-in-residence, Oral & Maxillofacial Surgery, University of California-Los Angeles School of Dentistry, and the associate chief of staff/director of graduate medical education, VA Greater Los Angeles Healthcare System. Address correspondence to Dr. Friedlander at VA Greater Los Angeles Healthcare System, 11301 Wilshire Blvd., Los Angeles, Calif. 90073, e-mail arthur. [email protected]. Dr. Bertolami is the Herman Robert Fox Dean, New York University College of Den tistry, New York City. 1. Presidential Commission for the Study of Bioethical Issues. Anticipate and communi cate: ethical management of incidental and secondary findings in the clinical, research, and direct-to-consumer contexts. December 2013. http://bioethics.gov/sites/default/files/ FINALAnticipateCommunicate_PCSBI_o.pdf. Accessed June 15, 2014. 2. Almog DM, Padberg FT Jr, Carmel G, Friedlander AH. Previously unappreciated carotid artery stenosis diagnosed by cone beam computerized tomography. J Oral Maxillofac Surg 20i3;7i(4):702-705. 3. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes toward chairside screening for medical conditions. JADA 20io;i4i(i):52-62. 4. Bertolami CN. Moving ethics curricula forward. Ethics Biol Engineer Med 201152(2): 87-106.
http ://ja d a .a d a .o rg
Septem ber 2014
911
Copyright of Journal of the American Dental Association (JADA) is the property of American Dental Association and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
