A few weeks ago, while browsing my Facebook feed, I came across a news story about a male dental hygienist who recently had his license revoked.  The reason for losing his license?  He was guilty of “sexually abusing” a patient.  What did this monster do you may ask?  According to the article, he had the audacity to clean his wife’s teeth!  For those not familiar with this story let me give you a brief summary and then I’ll get into what I see as the underlying problem.

Alexandru Tanase is a dental hygienist who lives and works in the Canadian province of Ontario.  In that province it is unlawful for a dental hygienist to have sexual relations with a patient, even if that patient is your spouse.  Yes, you heard that right.  Treating your spouse is considered “sexual abuse” in the great province of Ontario.

Here’s a timeline of Alexandru’s story in a nutshell.

In 2014, he starts dating his now wife.  Being aware of the dumb law at the time, he prudently stops seeing her as a patient.

In 2015, a fellow dental hygienist informs Alexandru that an exemption for spouses has been passed.  That person was incorrect (in 2015, an amendment to exempt spouses was submitted, but never passed by the provincial government).  Assuming his fellow hygienist was conveying accurate information, Alexandru resumes seeing his now fiancé from 2015 to 2016.

In 2016, his fiancé posts an innocent photo of her and Alexandru on Facebook right after getting her teeth cleaned.  Another hygienist (a former friend of Alexandru’s) sees the photo and subsequently submits a formal complaint.

In November of 2016 an investigator then shows up at Alexandru’s place of employment to ask a few questions.  And that is when his three year legal nightmare officially begins.

Now fast forward the story to September 2019.  His license gets revoked for five years and he is now labeled a “sexual abuser” by the government.

After reading the news story about Alexandru I then turned to the Facebook comments.  The comments were essentially all on his side.  People were describing the situation as “wrong”, “ridiculous”, “unbelievable”, “stupid” and so on.  The need to repeal this dumb law was painfully obvious.  But what happened to Alexandru, I will argue, is only a symptom of a more serious underlying problem.  Let’s get into the argument, but first, we need to define patient autonomy.

One of the things we learned in dental hygiene school is the concept of patient autonomy.  Phyllis Beemsterboer, RDH, MS, EdD, FACD describes the concept well:

“Autonomy is the principle that embraces respect for persons, the ability to be self-governing and self-directing.  An autonomous person chooses thoughts and actions relevant to his or her needs, independent from the will of others.  In health care autonomy gives rise to the concept of permitting individuals to make decisions about their own health…” (1)

This is in stark contrast to what has been done historically.  Up until the 1950’s, the relationship between clinician and patient was much more paternalistic.  What is the difference?  Here’s an analogy.  Paternalism is like an adult (or parent) to child relationship while patient autonomy is more like an adult to adult relationship.  In the former, the child is not fully autonomous, but in the latter, the adult is.

Patient autonomy is so important and valued in today’s society, as it should be, that patients are free to make what some may describe as completely idiotic choices regarding their health (e.g. ignoring an oral cancer diagnosis). Why is that allowed?  Because we still tend to see individuals as free, autonomous beings who should have the final say in regard to their own lives, good or bad.  But when it comes down to it, does society truly value patient autonomy?  Not really.

When the concept of patient autonomy is brought up in the abstract, the vast majority of people tend to agree with it.  But when you bring up concrete examples…well…that’s when the respect for patient autonomy starts to crumble.  Let’s look at just one example.

Every year roughly 800,000 Americans have dental treatment completed outside of the United States (a.k.a. Dental Tourism).  Saving money seems to be the primary reason for doing this.  Many in the US, including many dental professionals, would not recommend seeking dental treatment in places like Mexico, Columbia or Thailand (these are some of the more popular destinations).  In their view, the average quality is too low, but most importantly, the risk of adverse outcomes is too high.  But if you ask these same people if this activity should be illegal, the answer is usually no.  Why?  Well, one reason seems to be the respect for patient autonomy.  As Phyllis puts it in the quote above, the patient’s ultimate choice is “…independent from the will of others”, and “others” includes dental professionals.  So when it comes to dental tourism, the strong support for patient autonomy still holds, which is good.  But let’s see what happens when we change just one variable—location.

This is a hypothetical story about Dr. Costa and his patient Maria.  Dr. Costa has been practicing dentistry in Brazil for the last 20+ years.  At 50 years old, he and his wife decide to emigrate to the United States to be near their kids and now grandkids.  Because Dr. Costa’s English is very limited and because he cannot practice dentistry in the US with his Brazilian credentials alone, he is currently working in a warehouse and earning $12 per hour.

One day, while grocery shopping, Dr. Costa runs into a former patient.

Maria:  Hey Dr. Costa!  Long time, no see.  How are you doing?  My cousin told me you and your wife finally made the move.

Dr. Costa:  Yeah, finally did it.  Things are good.  It’s especially great being close to the kids and now grandkids!

Maria:  That’s great to hear!  Have you opened up a dental office yet?  If so, I want to make an appointment : )

Dr. Costa:  Well…no.  You know.  My English is….

Maria:  Ahhh…don’t worry about your English.  There’s a large Brazilian community right here.  You’ll have plenty of business.

Dr. Costa:  It’s not just my English holding me back.  I’m not allowed to practice without a US license.  And to get one I would need to complete the last two years of a US dental school…and slots are limited for foreign trained dentists in those programs.  Then I would have to complete board exams.  By the time my English is up to speed and by the time I complete the program…I don’t know…at my age…I’m not sure it’s worth it or even realistic.

Maria:  Why would they require all that?  That’s ridiculous!  You were a great dentist in Brazil and patients really loved you and I have no doubt people will love you here too.

Dr. Costa:  I appreciate that Maria, but it is, what it is.  I wish I could just open a practice or work for another dentist…maybe with a focus on serving the Brazilian community.  I have at least another 10 years in me. I don’t know.  Like I said…it is, what it is.

In the first situation an American travels to a foreign country for dental treatment and society in general is okay with it legally, regardless of risk.  Whether it’s government entities (e.g. dental boards), organized dentistry (e.g. ADA) or your average citizen, no one (or very few) is publicly advocating, or believes, that we should stop this activity through coercion (e.g. legal means).  Some might not like or recommend it, but they wouldn’t advocate forcibly stopping it.  In this case, patient autonomy is being respected.

In the second situation, Maria would be free to choose Dr. Costa, with his current credentials, if they were both physically located in Brazil, but because they are both physically located in the US, that choice has been taken away.  Does location affect the morality of the actual dental treatment?  No.  Does location affect the risk of the actual dental treatment?  No.  Does location affect the quality of the actual dental treatment.  No.  In this case, patient autonomy is not being respected.

So what is the fundamental question here?  The fundamental question here is not, should it be legal for Alexandru’s wife to choose him to be her dental hygienist?  Or should it be legal for Maria to choose Dr. Costa regardless of location?  The fundamental question here is this.  Who gets to decide?  Does the autonomous patient get to decide or does a central authority get to decide?  I pick patient autonomy every time.

In conclusion, the next time a law or regulation related to dentistry is discussed, first ask, how does it affect patient autonomy?  Or to put it more precisely, does it leave each patient free to make the choice “…independent from the will of others”.  Because THAT is the underlying principle that guides a truly free society.  And THAT is the underlying problem in Alexandru’s case.

Thankfully, Alexandru has had his license temporarily reinstated, but the fight is not over.  Alexandru still needs our help.  You can help in two ways.  Sign his petition and/or donate to his legal fund.  I’m sure he would greatly appreciate it.

Petition
https://www.change.org/p/to-all-the-people-that-feel-my-pain-and-think-i-matter-as-a-human-being

Legal Fund
https://www.gofundme.com/f/ukpeh

Works Cited
(1) Ethics in Dentistry: Part I – Principles and Values – Autonomy
https://www.dentalcare.com/en-us/professional-education/ce-courses/ce510/autonomy