You have been a patron of the same dry cleaner facility for over 2 decades. Gina has been the smiling cashier who welcomes you for as long as you can remember. She is a widowed, hard-working immigrant who barely speaks English. You’ve always noticed her crowded dentition, but the sincerity of her greeting usually overshadows the overlap of her incisors. Today, however, she seems glum. As she hands you your laundered dress shirts, she asks whether she can speak to you in privacy. In a secluded section of the store, you notice that she is wearing a set of aligners. After apologizing to you that her long working hours prevented her from seeking treatment from you, she explains that she prepaid for the entire treatment elsewhere to obtain a fee reduction. Unfortunately, soon after she did so, her orthodontist passed away. The orthodontist who assumed the practice has no interest or intent in providing further treatment, or even a fee refund to her. He insists that her treatment is now complete. Yet the irregularity of her incisors is obvious. When she called the deceased orthodontist’s wife to inquire whether a refund is an option, she received a recorded message that stated that the deceased orthodontist’s wife had divorced him, and therefore the ex-wife bore no responsibility to present or former patients. Even worse, Gina confesses that she never signed the financial contract she received when treatment commenced. She feels helpless and begs you for guidance. You can only imagine the sacrifice she has made to accumulate the payment for orthodontic care. With her financial situation, Gina cannot afford the potential loss of the treatment fee if she goes elsewhere.
You tell Gina you will consider her predicament and will contact her soon. As you leave the parking lot, you shake your head knowing that an unsigned contract for service is an unenforceable document. She has no legal recourse with the practice. But as a vulnerable patient, is she entitled to something more? Does a practitioner’s ethical responsibility exceed a contractual agreement, even though unforeseen consequences arise? When it comes to fidelity (keeping one’s promise) as members of an elite profession, might we be even minimally responsible for promises made by a colleague when expectations cannot be fulfilled? Is orthodontic treatment just another business deal?
When a doctor-patient relationship is established, the doctor assumes the responsibility of fidelity. There are 2 aspects of fidelity in health care. The first is that the professional maintains the patient’s interests over his own. The second is that the professional prioritizes the patient’s interests over those of others. Finishing and detailing a patient optimally long after the insurance remuneration has ceased or after the financial contract has been satisfied—with the intent to provide the best possible treatment result—is an example of fidelity. Forgiving an outstanding fee that resulted from hardship because of the loss of employment or the death of a parent can be viewed as an act of fidelity, as well as one of generosity. Yet, when the professional’s personal interests override the best interests of the patient, conflicts of interest can arise. These conflicts might obscure the most appropriate ethical course on the patient’s behalf. Ultimately, the patient pays the price by failing to receive his or her due.
Fidelity is essential because of the disparity in knowledge between the professional and the patient. State dental boards might remand a practitioner who breaches fidelity, but unless a legal transgression occurs, the vulnerable patient is stranded with few alternatives in remediation. When fidelity has been violated, the patient often has little recourse and remains at the mercy of the provider.
Remediation in Gina’s case can be at your discretion. At the very least, and with Gina’s permission, a call from you to her new orthodontist to explain her desperate predicament and her desire to complete treatment thoroughly would be an act of fidelity executed on behalf of the profession. Hopefully, his level of fidelity—and empathy—will place Gina’s interests above his own.