Mrs Greene is your last patient of the week. Despite her Class II dentoskeletal relationship, she is an attractive middle-aged woman who was referred by a top-notch periodontist to upright her mandibular molars. The periodontist plans to deliver bilateral posterior implants to replace the absent mandibular first molars. During your discussion with Mrs Greene, she confides that her deficient chin has always concerned her. You suggest that a full set of diagnostic records be produced, followed by a discussion of treatment options.

A review of her records indicates that mandibular advancement surgery would not only place the implants in a superb occlusal relationship, but also directly address her complaint of mandibular retrognathia. After referral and consultation with your oral surgeon, you receive a call from Mrs Greene. She says that she will surely proceed with the mandibular advancement surgery. She sheepishly adds that while she was in the surgeon’s reception room, she saw photographs of several patients in whom the surgeon had completed both an orthognathic procedure and implant placement. Mrs Greene says, “I felt a much better connection with the surgeon than with the periodontist. Can’t I just have the surgeon do both procedures and not return to the periodontist?” A pregnant pause ensues from your end of the line. How should you answer her?

One corollary of the ethical principle of fidelity is loyalty. Loyalty between professionals is a universal obligation, ascribed not only to Western medical ethics but also to other cultures. The Islamic Code of Medical Ethics Kuwait Document in “The Oath of the Doctor” states that “I swear by God . . . The Great . . . to revere my teacher, teach my junior, and be brother to members of the Medical Profession, joined in piety and charity.” An ethical dilemma evolves when a patient expresses favoritism for a second practitioner who is equally qualified to execute a procedure offered by the original referrer. And ethical responsibility aside, it is merely common sense to reason that a referral from one practitioner that is diverted to another will probably be the last from that source in the future.

The crucial issue in your response to this patient’s choice of who will provide the implants lies in the degree of autonomy you will grant her. Some believe that one direct benefit of autonomy might be the possibility that a person knows what is best for himself or herself. However, patients can act out of ignorance of the facts, including the skill level of a potential provider, or misjudge the implications of their decision. Other patients will sacrifice their own welfare for the sake of others. Consider parents who have said, “I’ll wait until my son completes orthodontic therapy and then consider it for myself.” Patients might also behave impulsively or emotionally without regard to a clinician’s experience or advice in choosing specialty care. Their choices can also be made on a whim or based on a short-term criterion such as a price comparison that might not warrant the difference in treatment quality. Your guidance is therefore critical more often than not.

The solution to your dilemma should be based on the potential benefit to the patient. If both providers are known to deliver the same level of service and the difference in the benefit to the patient is negligible, you should recommend that she receive the implants from the periodontist who made the initial referral. If there is a known history of inadequate quality of care by the periodontist, you have a more complex ethical issue at hand. At any rate, the next time you are involved in the possibility that 2 providers can deliver the same service, you’ll call ahead to both clinicians to clarify who should provide which service. As Ben Franklin said, “An ounce of prevention is worth a pound of cure.”