One of your patients is a college professor who has lost multiple teeth. The original treatment plan calls for uprighting the posterior quadrants followed by restorative rehabilitation with both conventional and implant-supported prostheses. As for all your interdisciplinary patients, you conduct a pretreatment conference with the restorative dentist and the periodontist, and then enroll the patient in a 24-month treatment plan consummated by a signed consent form and a financial contract. Despite the patient’s devotion to treatment, root divergence for implant placement after 27 months of fixed therapy is inadequate. A complication in case management is the sudden retirement of the restorative dentist because of newly diagnosed multiple sclerosis. The patient is dissatisfied with the dentist’s successor and implores you to find an alternate provider. You expend extra effort to satisfy both the patient and the collaborating periodontist by integrating the new dentist into the rehabilitation effort. After several more months of fixed therapy at no added fee, you obtain a treatment result that satisfies the patient, the periodontist, and yourself.
Despite the best intentions of all involved, your commitment to this patient far surpasses your contracted 24-month treatment plan. Because there are so many other patients for whom you act as a liaison to other health care providers and consistently “go the extra mile,” it seems apparent that the doctor-patient relationship often exceeds that of a contract.
By definition, a contract involves an offer and acceptance (presentation of treatment options followed by the patient’s agreement to proceed) in exchange for payment for professional services (consideration). In many cases, however, the orthodontist’s commitment and dedication to the patient’s welfare extends so much farther in time and effort. As an alternative to the basic notion of a contractual agreement, some medical ethicists describe highly effective relationships between doctor and patient as a covenant . Defined as a “formal binding agreement” and often used in a religious context, a covenant encompasses the doctor’s moral and personal core in promoting good for the patient. This commitment supersedes the fundamental legal obligation of a contract. A covenant not only incorporates the doctor’s knowledge and experience in providing optimal care, but also enlists the idea that moral character beyond clinical skills is to be used to facilitate good for the patient. It is a concept of benevolence that stems from a genuine effort to be helpful.
The covenant concept in health care is not new. It is an enduring notion that our actions stem not merely from execution of a written document, but rather from who we are. Patients are often keenly aware of our sincerity, and develop trust and respect for us both as clinicians and persons. Moses Maimonides (1135-1204), a scholar who explored medicine in relation to Jewish law, noted the importance of morality and good character in the establishment of trust in the doctor-patient relationship. He wrote, “May neither avarice (greed) nor miserliness, nor thirst for glory, nor for great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to my patients.” Maimonides was describing the ethical principle of fidelity: that the promise we make to provide optimal care to our patients is to be honored above all.
Those who have served on an admissions committee are aware that the ultimate challenge in the identification of potentially successful caregivers lies more in the assessment of character and morality than in intellectual prowess. Students and residents who can embrace their patients in a covenantal relationship often develop into professionals whose morality and character foster a lasting trust from their patients and those around them.