Many years ago, around the time I began teaching full time, a friend and colleague who was in private practice had a serious medical problem and had to quit working. He had a small, 2-chair office, but the practice was very busy. So, every Saturday for about a year, I drove a good distance to his office and saw a week’s worth of patients in 1 day; sometimes I had help from another orthodontist and sometimes not. The practice employed a dental assistant and a receptionist, and the doctor who was ill had a wife and 2 small children who depended on the practice… and there were additional medical bills to pay. There was also a nervous accountant in the mix who would stop by at the end of the day to make sure that enough revenue had been produced to keep everything and everyone going. My compensation amounted to 2 sandwiches every Saturday: one to eat on the fly during the day and the other to eat on the way home.

A few months into this arrangement, on a Saturday morning, the receptionist told me that the practice’s best referring dentist wanted to stop by at the end of the day to talk to me about a patient. Through observation of the many patients that he had previously referred, I knew that he was an excellent dentist, so all I could think was that this is not good news—someone we are treating must be complaining. Well, at the end of the very busy day, the dentist showed up, but to my surprise he brought a patient with him whom I had never seen before.

It quickly became obvious to me that this dentist was a nice fellow, but he had a problem. He explained that he admired the work produced in our orthodontic office, and he thought he would like to learn how to do some orthodontics himself. So he had taken a course, sent some models off to a laboratory, which made an appliance and sent it back to him (with a set of instructions), and he cemented the appliance in place; this was his first orthodontic case. Subsequently, he became concerned because nothing much had happened. So on this day, he wanted me to look at the patient and give him some advice. At that moment in time, I would have very much preferred to be talking with the nervous accountant instead, or better yet, behind the wheel of my car eating my second sandwich, but I mustered up the courage to take a look.

A cursory glance showed a crude and unusual expansion appliance affixed to the maxillary molars and premolars. I also noted that the poorly cemented bands on one side of the mouth had come loose, probably some time ago. I remarked something to the effect of “I am not familiar with this exact appliance, but it appears that it could produce the intended effect. Even so, it needs some adjustment.” The dentist muttered, “Like what?” Without words, I took a scaler and inserted it into the tangled weave of expansion wires and pulled the appliance down so that it was obvious to the onlooking dentist that the bands were loose on one side of the mouth. The dentist became red in the face and motioned to me that he wanted to have a private chat. Once we were in private quarters, in an excited tone, he said something such as: “I get it: the appliance can’t work if it isn’t cemented. She’s already paid for the appliance. Now what do I do, and how can I do it without being embarrassed and losing my patient?” This was a real dilemma for him… and for me also.

A million thoughts raced through my mind regarding my duty in this situation. There were thoughts about my duty to a dental colleague who was “the best referring dentist,” thoughts about a patient who really wasn’t a patient of mine or of the practice I was covering; there were the jobs of the 2 employees and the accountant, there were the needs of the orthodontist who was ill, not to mention the needs of his wife and 2 small kids. And finally, thoughts about myself: I was working in a practice that wasn’t mine, I wasn’t being paid, I was just trying to keep things going for the practitioner when he returned, or keep it valuable enough to sell if he couldn’t return. What to do? I had passed all the ethics courses that I had ever taken, but this complicated scenario was never addressed on any of the tests I had encountered.

What I came up with was the following. I told the dentist that I believed that our course of action should be directed toward the best interests of the patient. I told him that rather than recementing the appliance and continuing, it should be removed, the teeth cleaned, and the appliance sterilized and packed carefully into a small elegant box to be kept by the dentist. Then the plan for this patient’s orthodontic treatment should be reconsidered by the dentist, and the best course of action discussed with the patient. I offered to explain this to the patient for him. The dentist was relieved and pleased, and as it turned out, when the appliance was removed, the patient was also pleased.

Subsequently, the dentist continued to be the best referring dentist for that practice. The practice was ultimately sold, and I never learned what became of the patient. But for the next 20 years or so, I thought about the situation every now and then. I also talked to “ethical” people about it, and they all tended to agree that I had handled things fairly well. But I was unable to shake a nagging concern as to whether I had done the best thing possible. Well, many years later, when researching another topic (expertise), I came across some information that allowed me closure.

It has been pointed out many times that dentistry is both a profession and a business. This dual consideration can be the cause of some confusion. Although a business should never provide false information to a customer, it is acceptable and fairly normal practice for a business to selectively point out the virtues of its products, emphasizing only their positive qualities. A profession, on the other hand, is supposed to operate differently in that it must regard the betterment of the customer as its highest responsibility. One thing that guides a profession and the creation of its ethical principles is the concept of fiduciary duty.

As applied to dentistry, fiduciary responsibility involves a recognition that an unbalanced relationship exists between the doctor and the patient. One person (the doctor) is in a position of power as an authority with vastly superior knowledge and skills; the beneficiary (the patient) is weaker and relies on the fiduciary (the doctor) to meet his or her needs. Patients know little or nothing about dentistry, they cannot diagnose their own dental problems, they cannot treat themselves, and it can be difficult to judge the doctor’s level of knowledge and skill. Because of this imbalance, the doctor must always promote the best interests of the patient, must have the expertise to serve the patient, must inform the patient properly and fully, must disclose his or her qualifications honestly, and must disclose and discuss real or perceived conflicts of interest. To do otherwise would allow an opportunity for inappropriate domination and influence, and even deception or exploitation of the patient.

The doctor must exercise the duties of a fiduciary in all aspects of the doctor-patient relationship, but 2 main duties are involved: the duty of loyalty, and the duty of care. The duty of loyalty to the patient is expressed as good faith, honesty, and fair dealing so that the doctor always acts in the interest of the patient rather than being driven by his own interest; this affects things such as contracts, confidentiality practices, and informed consent, among others. Of course, the doctor can receive a fee for services rendered, but the nature and the amount of that fee must be disclosed before beginning treatment.

The duty of care requires that the doctor be knowledgeable and skilled and provide care that is appropriate, efficient, and effective; treatment must be performed at the highest level of care the doctor is capable of providing.

In the end, becoming familiar with the concept of the duties of a fiduciary proved to be an appropriate personal guide that could be applied to ethical situations arising in patient care, teaching, and other aspects of professional life. These concepts helped me, but no one can force such ideas on others, without willing reception and consideration.

Rolf G. Behrents

I came to realize that life lived to help others is the only one that matters and that it is my duty… This is my highest and best use as a human.

Ben Stein (actor, novelist, columnist, economist, lawyer, speechwriter, commentator, comedian, and game-show host)