- BIOETHICS FORUM ESSAY
In 2008, The President’s Council on Bioethics turned to Immanuel Kant and his deontological philosophy as a resource for deliberations on contemporary bioethical issues. The report focused on Kant’s understanding of human dignity, and his deduction that the value of a human is intrinsic. The Council ultimately asserted that according to Kantian moral philosophy, worth is also inherently attributed to the physical being of an individual, which “argues for humility when confronted with new opportunities for . . .’enhancements’ of the human organism.” Essentially, Kant condemns attempts to surpass what might be called natural function, attempts typically described as transhumanist efforts. From this, it can be concluded that Kant may disagree to some extent with the aims of modern orthodontics.
A seminal study in 1998 based on data collected by the third National Health and Nutritional Examination Survey concluded that 57 percent to 59 percent of the United States population was in need of orthodontic treatment. More recent epidemiological data worldwide has yielded comparable results. Malocclusion prevalence was found to be 54.6 percent in Iranian children, 95.6 percent in Libyan children, and 75.8 percent in Italian children. Similarly, 84.98 percent of Nepalese children and 53.2 percent of Brazilian children were determined to need orthodontic treatment.
Adopting a strict statistical definition of normal, it would appear that malocclusion, despite not being physically ideal, is indeed the human normal. Thus, efforts to correct malocclusion could be construed as a violation of Kantian human dignity – it is an enhancement. While perhaps not in so radical a way as genetic engineering or artificial intelligence, orthodontics is a profession that has both historically strove, and presently strives, to perfect a particular aspect of imperfect beings.
Assigning a need for orthodontic treatment encompasses consideration of an immense variety of interventions and a spectrum of malocclusions. Since the most severe conditions have real health consequences, all malocclusions should not be judged as morally equivalent. We are not arguing that orthodontists should not seek to improve their patients’ health and quality of life in any way they can. However, it may be appropriate to allow for the humility called for by the Council’s report when making orthodontic value judgments. More importantly, orthodontists must recognize the immense influence of Kant on modern Western civilization. Many patients may wish to preserve their “natural” appearance, and take issue with modifying what was bestowed to them in the absence of human intervention.
When navigating such situations, and attempting to balance paternalism, autonomy, and beneficence, it is important for orthodontists to realize that such patients have Kant in their corner. Take, for example, a patient who exercises their autonomy and declines treatment of their mild malocclusion, saying, “I won’t look like the real me.” In this situation, orthodontists are likely to instinctively focus on the imperfect aesthetics and risk of dental caries associated with crowded teeth, and may squirm at the rejection of their beneficent intentions. Orthodontists may be tempted to act paternalistically, believing their view to be the most valid. However, the views expressed by the patient are not only inculcated in Western culture, but are also, to many, philosophically valid. In recognizing this, an orthodontist would be much better equipped to engage with the patient, and to successfully navigate the ethics of the situation.
Central to the concern with medically altering a human normal, both in the eyes of Kant and of those who oppose transhumanism, is that the normal is subsequently redefined. Granted, the ubiquity of orthodontic care is partly due to demand, as Kant’s convictions are not held by all. Within the context of these market forces, orthodontic education has naturally focused more on the can and how, rather than the ought. As a result, orthodontic treatment is rapidly becoming a social expectation, and not without the possibility of negative ramifications for some individuals. Those with malocclusion who cannot afford orthodontic care may become a marginalized minority, despite being in the genetic majority, presenting an ethical concern regarding distributive justice, and the possible exacerbation of social disparities.
In this day and age, misaligned dentition or an unaesthetic smile can seriously impact an individual’s level of confidence, functioning and achievement in life. It is important for orthodontics as a profession to be cognizant of its role in society, and how it impacts both those in its care and those outside its care – all of whom Kant asserted have intrinsic worth.
Steven Daws and Hassan Khan are master of bioethics candidates at the Perelman School of Medicine, University of Pennsylvania, and doctor of dental medicine candidates at the School of Dental Medicine, University of Pennsylvania.