Ethics in the pursuit of Esthetics*

Meropi N. Spyropoulos, DDS, Dr. Odont., MS**

* Summary of a paper presented at the AAO 106th Annual Meeting, Las Vegas, 2006.
** Professor of Orthodontics, University of Athens, Greece.

www.lingualnews.com Vol 4 No 2 September 2006

Introduction
We live in an era where the pursuit of "good looks" has become a major goal of everyday life , as "looks" seem to be one of the most important and significant assets for success. At the same time, success is widely considered to be synonymous with wealth, glamour, publicity etc. On the other hand, it seems that the concept of "good looks" and "success", oftentimes undervalues, ignores or clashes with some ethical parameters. Therefore, since our profession offers services that promote facial esthetics and attractiveness, the aim of this paper is to provide some insight on the involvement of ethics in the pursuit of esthetics and the dilemmas associated with this issue.

Definitions
In order to better understand the concepts and ideas that will be presented here for discussion, it is necessary to remember the definitions that are relevant to some terms associated to the topic:

Esthetic(aesthetic): What is pertaining to, or sensitive to the beautiful. What is in accordance with principles of good taste.

Cosmetic: Designed or having no other function than to beautify.

Beauty: Combinations of qualities (e.g. form, colour, size etc.) that delight the eye. Combined qualities delighting the other senses, the moral sense or the mind.

Ethics: The study of the general nature of morals and of specific moral choices. The rules or standards governing the conduct of the members of a profession. Any set of moral principles or values that govern the character and conduct of an individual or a group.

Moral: What is concerned with the discernment or instruction of what is good or evil. Being or acting in accordance with established standards and percepts of good behaviour. Arising from conscience.

Fig 1:"Conscience" receives and sends messages concerning various parameters and concepts, which finally dictate behaviour.

Conscience: Moral sense of right and wrong, as regards decisions for which one is responsible. Conformity to one's own sense of right conduct.

Changeability of concepts and criteria: All the above parameters are eventually involved, in one way or another, with the dilemmas with which we are faced, during the decision making procedures in some aspects of our profession. It is also a fact that there is always a reciprocal feed back between what is defined as "conscience" and various other parameters such as: concepts of beauty, of professional conduct, of ethics, of science, of social status, and most certainly the demands of the patient (fig.1). It is, therefore, interesting to focus our thoughts on how some of these parameters, affected by certain factors, become changeable through time.

Factors influencing the concept of beauty: Since our topic is concerned with the notion of esthetics which is directly associated with the concept of beauty, it is relevant to point out that this concept is influenced by and changes with: Time-era, geographical location, cultural doctrines, fashion, promoted idols of the show business.

Characteristic examples of some of the changes observed in what has been considered as the esthetic ideal, are seen in the art of neighbouring civilisations during the same era , or in the art of ancient Greeks in different geographic locations and times, as well as under the influence of spiritual, mechanistic or cultural orientations(figs. 2 - 5).

"rationalism without humanities, renders science insufficient" and that there is a close relationship between medicine, philosophy, cultural education, religion, and faith. Also, he gives paramount emphasis to the necessity of the "love of man" in order to love the medical art, and to the importance of a whole psycho-socio-somatic approach to the patient. However, he wisely concludes that "Life is short; and the art (of medicine) is long; and the right time only an instant; and treatment is precarious; and the judgement difficult".

The changes in the ethical aspects of contemporary everyday life, have undoubtedly touched all professions. As far as our profession is concerned, the related literature increases by the day and articles with titles such as "Esthetic Dentistry and ethics" (Christensen 1989), "Requests for treatment: ethical limits on cosmetic Dentistry" (Chiodo and Toole 1993) or "Where is the Ethics in Aesthetic Dentistry" (Hussey 2002), only show the summit of the iceberg. And in spite of the fact that there are Codes of Ethics and of Professional Conduct, issued by the Dental Associations of almost every country, an honest approach to the matter leads us to admit the following:

a) "The dental profession has to ensure that we are able to justify our treatment plans, based on true clinical need, but also allowing patients to have an acceptable level of input"(Hessey 2002), and
b) Ethics is violated in cases of
(i) unsatisfactory treatment,
(ii) overtreatment,
(iii) overcharging,
(iv) convincing patients to accept services that are not really necessary

In the field of Orthodontics: If we try to summarize the most consistent findings of the great number of clinical and epidemiologic studies, performed in the course of the last 40-50 years, which were aimed to reveal, specify and evaluate the esthetic goals of Orthodontics in correlation with cephalometric and other standards, we end up with the following observations:

a) Irrespective of the methodology used in every approach, it seems that "dentists and lay persons judge facial esthetics d i f f e r e n t l y", "there is evidence that a wide range of facial form is within the public's concept of pleasing esthetics", and obviously "no numbers or devices can t o t a l l y express the complexities of facial esthetics".

b) When evaluating the esthetics of the smile , a major method error is possible - and has influenced many results-because the parameter of 'function through time' has not been incorporated in the static records taken. Photographic capture of a smile at the moment of its supposed peak, could be unpredictable and of doubtful validity, because of the speed of the process (Sarver and Ackerman 2003 , Tarantilli and al 2005) , and

c) There is a number of other very influential factors that have never been included in any of the evaluation procedures. In these factors we can include expression, poise, hairdo, skin complexion, cleanliness and neatness, attitude and disposition, changes with growth (Behrents 1985), changes with weight, changes with age, and other characteristics specific to every specific individual.
Some characteristic examples of the effect that the above factors can have on the attractiveness of a face are seen in Figs. 7- 10.

Reciprocal examples, documenting the absence of any adverse effect of a malocclusion or a convex profile on the attractiveness of certain faces, are given in Figs. 11 - 14.

Discussion
There is no doubt whatsoever that esthetics, from ancient times to this day, play a very important role in human life. In spite of the fact that the famous author Alexander Pope notes that "Beauties, in vain their eyes may roll; charms strike the sight, but merit wins the soul", and Moliere , even in the extremely sophisticated French society of the 17th century, points out that "Beauty of face is a frail ornament, a passing flower, a momentary shine which is not attached but to the skin", orthodontists whole heartedly agree with the following wise statement of Victor Hugo:"The beautiful is as useful as the useful. Perhaps more so".

Nevertheless, our patients are not just faces and occlusion. Keeping in mind that "If a whole patient is to be treated well, it requires, surely, a completely whole doctor: that is, a scientist, an artist, and a philosopher"(Robert E. Moyers), we understand that a w h o l e doctor is the one who offers services for health and beauty, that are really good to the patient, being always conscientious of and respectful to values of ethics and moral.

The pursuit of the ideal can often be a utopia and an unnecessary service to the patient.
"Every man should be judged by measures within him" said Aristotle. Therefore, although oftentimes art copies true life and life copies art (fig. 15), it is appropriate to point out that Orthodontists should be:
a) sensible and wise enough, to remember that we are not painting frescos,
b) humble enough, to realize that there is no equation that can express and secure the warmness of a beautiful smile,
c) proud enough, to assume the responsibility of serving every individual that comes to us with confidence and honors us with his or her trust- always in the best possible way, and in respect to what is really g o o d for them, and
d) interested enough, to help our patients find out , improve and enjoy their best individual assets.

In this era of crisis in ethics and honesty, we should often stop and think whether we are gradually, but constantly drifting into becoming a profession of indifferent tecnocrats , and how much of what we do is really for the benefit of our patient, or is it for our own pride and benefit.Then , and only then , we can call ourselves "true professionals" i.e. "individuals who have special knowledge and skills used to benefit the public, regardless of personal gain"( American College of Dentists 2004).

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Adult and Lingual Orthodontics
EDITORS:
Dr. Silvia Geron D.M.D., M.Sc
Dr. Rafi Romano D.M.D., M.Sc
Dr. Pablo Echarri D.M.D., M.Sc