They were not allowed to extract the tooth without consent

The deputy protector of human rights and freedoms, Nerma Dobardžić, found that in the case of a patient with autism, the Clinical Center (KCCG) violated her rights prescribed by the Constitution of Montenegro and the European Convention for the Protection of Human Rights and Fundamental Freedoms.

"Recalling that the individual's right to refuse treatment falls within the scope of Article 8 of the Convention, and that medical intervention against an individual's will leads to interference with his right to private life...", it is stated, among other things, in the conclusions of the deputy protector on this case.

The Constitution stipulates that everyone has the right to respect for private and family life.

The complainant is the father of a 28-year-old female patient, who had a dental intervention on March 3 at the Clinic for Otorhinolaryngology and Maxillofacial Surgery, KCCG. In the complaint, it is written that this type of intervention for people with special needs involves a special procedure and that it is done under total anesthesia, that three of her teeth were extracted without seeking his or his wife's consent, that they did not take an X-ray before the intervention, but that the doctors taken out based on free judgment...

The director of the KCCG informed the protector's office that all actions in this case were carried out according to protocols, as well as that the medical documentation contained the mother's informed consent to the procedures undertaken.

The director of the Dental Clinic informed the protector's office that during the first examination of the patient, her mother was explained that there are teeth that should be extracted and those that could be repaired, which the specialist doctor confirmed in his report.

After such an explanation, upon admission to the Clinic, the mother signed an informed consent to the medical procedure, and it is stated that the dental intervention "was not carried out against the mother's will when it comes to two teeth".

Specialist doctors stated that after putting the patient under general anesthesia, they performed a detailed clinical examination of the oral cavity, considering that the examination of such patients in ambulatory conditions is difficult, and often impossible.

The document states that in this case it was not possible to perform an X-ray of the teeth before the intervention due to the patient's lack of cooperation due to autism. While trying to save one of the teeth, doctors noticed pus and decided to remove it, explaining to the guardian's office that any acute dental infection can be life-threatening, especially in populations such as people with developmental disabilities.

She was informed about the extraction of the third tooth after her daughter woke up from general anesthesia.

In the response, the protector of patients' rights and the assistant director for quality control of the provision of health services, among other things, state that "the written consent did not include a description of the planned medical procedure, precisely because it was not known at that time what would need to be done during the intervention under general anesthesia, but because of this, during the intervention in front of the operating room, the patient's mother was given a detailed description of the activities to be undertaken".

Without diminishing the importance of the mother's responsibility, which she took on behalf of her daughter by signing the statement on informed consent, the deputy protector states in her opinion that the statement does not contain any information that the prescribing physician was obliged to present in accordance with the Law on Patients' Rights.

Dobardžić notes that upon inspection of the statement of informed consent for the application of the medical procedure, signed by the mother, it is established that apart from the name of the patient, not a single aspect of the medical procedure was specified or explained.

"In addition, the statement does not contain the signature of the prescribing physician, who, as previously stated, should have informed the patient, i.e. her mother, about all aspects of the proposed procedure, including the consequences and risks, with a detailed statement form," writes the deputy protector.

It also says that certain doubts regarding the accuracy of the number of teeth proposed for treatment, and especially extraction, had to be an integral part of the completed declaration form, in which way the patient's mother would be informed in time of possible complications and side effects, based on which was able to make a decision on intervention.

The doctor's statement that upon leaving the operating room they informed the mother that seven teeth had been repaired and that three had been extracted, according to the opinion of the deputy guardian, confirms that the patient's mother was not informed in a timely manner about all aspects of the treatment, possible complications and risks.

"All the foregoing indicates that the medical measures taken for the treatment and tooth extraction of patient XY are not based on the Law, which is clear, precise and predictable in practice, because their undertaking was not preceded by the informed consent of her mother, based on written, timely and complete information about the planned medical measure, which is clearly defined by the relevant provisions of the Law on Patients' Rights", states Dobardžić's opinion, where it is added that the formalistic approach to the issue of informed consent to the proposed medical intervention conflicts with the essence of the obligation of doctors to provide disabled persons with protection of the same quality as also provides to other persons, based on free and informed consent.

The Dental Chamber should not delay

The deputy protector recommended that KCCG invite the patient, her parents and representatives of organizations that represent the rights of PWDs to a meeting in order to find out directly what problems people with disabilities face in exercising their right to health care.

She also recommended that in all future situations, he undertakes medical measures only on the basis of the informed and free consent of the patient, i.e. his legal representative or guardian, based on timely and complete information about the planned medical procedure, as defined by the Law.

And the Dental Chamber was recommended to act without delay on the request to initiate the procedure submitted by the patient's father against the dentists who participated in the treatment procedure.

The request was submitted on March 23 and it was not decided until the opinion was issued at the end of July.

The Code of Dental Health Ethics concretizes the patient's right to refuse a proposed medical measure, even in situations where it is a question of saving or maintaining his life. In this sense, it is the duty of the dentist to point out the possible consequences to the patient and to obtain a written statement from the patient or legal representative that he refused to take the proposed medical measure.