Your downtown practice is growing slowly but surely despite the stagnated economy. One consistent referral source has been a large manufacturing plant, many of whose employees and families you have treated. Unfortunately, the recession has necessitated corporate layoffs and termination of employees’ orthodontic insurance benefits. Young Brian, the last of the 3 Davis children and the son of 1 such employee, has severe bialveolar protrusion. He has expressed his motivation for full orthodontic correction. The case appears to be straightforward and routine. After your initial evaluation of Brian, Mrs Davis asks to see you privately. As he exits toward the waiting room, Mrs Davis explains that her husband’s working hours have been drastically reduced and Brian cannot proceed with therapy without a fee consideration from you. She asks for a 50% reduction for his comprehensive correction. You pause momentarily, thinking that you certainly want to oblige her. After all, the family has been a strong referrer of other employees from the company, and the older Davis children have been a pleasure to treat. But if you grant a fee reduction to the Davis family, are you being unfair to others from whom you request full fees?

The ethical principle of justice involves treating people fairly and giving them what they deserve. Certainly, persons who are motivated to receive health care, including orthodontic therapy, should have the opportunity to do so. The orthodontist’s decision to allow selected patients a fee reduction might stem from several levels of motivation. Retaining a family in the practice or encouraging a referral source provides valuable “word of mouth” confidence in your service. Some practitioners might be generous and empathetic by nature, and truly enjoy providing an altruistic gesture when appropriate. Some luminaries in health care management have suggested that fees for services should involve a “sliding scale.” In this arrangement, those who can pay full professional fees should do so, and those who cannot can expect a fee reduction based on financial status or treatment need. Opponents to granting fee reductions opine that such a reduction unfairly shifts the burden of cost to those that are sufficiently affluent to pay full fees for professional services. Fee reductions could be viewed as arbitrary and biased, especially when 2 cases of equal complexity are assigned different fees. The objection might then be that such a fee modification is interpreted as a violation of the principle of justice, since all patients would not be treated fairly.

The concept of a variable fee scale is not novel and perhaps is even common. My father-in-law was a country doctor who was occasionally paid for his services with produce or livestock from grateful farmers if they could not satisfy his treatment fees with currency. Community medical services advertise sliding fee schedules based on patients’ Zip codes, because some geographic areas are more affluent than others.

Distributive justice is a subconcept of the ethical principle of justice and defines several options for allocation of services offered in a society. These services are not necessarily limited to health care and can include the availability of educational programs. One theory of distributive justice is that of egalitarian distribution. This concept acknowledges that not all people are created equally in terms of health, intellectual, or financial status. Such inequities can be based on circumstances beyond the person’s control and thus might be considered “undeserved.” Egalitarian justice involves an earnest attempt to remedy the situation for the undeserved. One opportunity to provide egalitarian justice is a health provider’s prerogative to modify a fee based on the patient’s need.

Mrs Davis is still waiting. What should you tell her in response to her request for a fee reduction? Given the family’s devotion to your practice, Brian’s level of motivation—and your belief that our specialty stands for more than just business—you might want to gladly oblige her.