Ms Samson returns to your office to discuss—again—the orthodontic options to address her maxillary anterior crowding. You gave her a diagnosis and several treatment options about a year ago, but she declined to return for treatment since then. As one of your city’s most prominent litigators, she had relegated orthodontic correction to a low priority in her life. Now she wants to start treatment immediately.

Her dentoskeletal malocclusion can be described as maxillary protrusion with mandibular deficiency. She has a protrusive upper lip with an acute nasolabial angle caused by maxillary sagittal excess. There is conspicuous maxillary anterior crowding. In her characteristically straightforward demeanor, she places 3 conditions on your treatment delivery: she declines surgery, she refuses extractions, and she wants treatment to be completed within a year. “I’m too busy for those other procedures or processes,” she says. “I just want these teeth to look good.”

You patiently explain that although you can straighten her maxillary anterior teeth, her protrusion will probably increase because of her treatment stipulations. She asserts that she will accept an increase in overjet but holds firm to her other requirements. You know that patient autonomy is essential—but her control of the treatment conditions is very concerning to you. You ask yourself: What are the limits of autonomy?

One component of the definition of autonomy (“self rule”) upholds the patient’s right to choose a treatment plan once the options are explained, including the choice of no treatment. This liberty appeals to those who oppose the spirit of paternalism (the doctor-dictated treatment choice regardless of the patient’s opinion), which pervaded the health care arena until the early 1980s. Informed consent implies that the patient has both the knowledge and the foresight to be able to make a wise decision on her own behalf. But does she?

The choice of treatment is sometimes difficult for even the most seasoned clinician. Consider a borderline extraction case in which profile concerns, cooperation potential, and constraints such as medical history or periodontal susceptibility might affect treatment prognosis or safety. If even the expert could be perplexed and might err in the treatment choice, how can a patient be expected to choose wisely?

Contemporary bioethicists now challenge the concept of total autonomy in health care. To grant full patient autonomy in treatment selection, irrespective of the consequences to her dental or general health, could be viewed as delinquency of one’s duty as a health care provider. For example, the delivery of a series of esthetic aligners to resolve severely crowded incisors, despite extremely thin keratinized tissue levels, can cause iatrogenic dehiscences of gingival tissue and bone. The improvement of tooth alignment may satisfy the patient’s chief concern, but the patient is ultimately harmed in the process.

The concept of a covenant relationship in contrast to a contractual relationship has been described in previous editorials. Whereas a contractual relationship requires an “offer and acceptance” followed by payment in exchange for the service—and no more—the covenant relationship ascends to a level of the doctor’s thoroughly engaged “competence, compassion, caring, and good communication” with patient trust as the unifying theme.

Authentic, mutually beneficial autonomy should represent a genuine collaboration between the doctor and the patient. Partnerships frequently require concessions by the involved persons to generate a mutual decision. Declining to become part of a treatment regimen—by either the patient or the doctor—is justified if doing so threatens dental or general health. This responsibility lies within the provider’s prerogative and should not be viewed as paternalistic. In Ms Samson’s case, her constraints might be too imposing to tolerate for either of you. Her demands exceed those of genuine collaboration.

I’ll never forget the admonishment of one of my favorite instructors that fell on our young, enthusiastic but deaf ears many years ago. “Never be afraid to see the backs of their heads!” he said emphatically. Puzzling then, but now crystal clear.