In retrospect, you realize you should have seen this coming. After 30 months of complex orthodontic therapy, your young patient’s previously impacted maxillary left canine is fully corrected. His occlusion is near perfect, and debanding should be scheduled within the next month. However, you recently learned that the patient’s single parent has been inconsistent in monthly fee payments. There is an outstanding balance, despite the signed contract. When questioned, the parent remains unresponsive.
You are faced with an ethical dilemma. Do you deband the patient irrespective of fee status, or do you insist on full payment for services before debanding? Section 3 of the American Dental Association (ADA) Code of Ethics refers to beneficence as follows: “The most important aspect of (the dentist’s) obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient.” Therefore, now that treatment is in its final stages, you are obligated to act in the best interest of the patient—and especially avoid harming him—without regard to his financial status. As a health practitioner, you are obliged to respect the concept of nonmaleficence : the duty to avoid the infliction of harm on others. Delay of debanding can significantly increase the potential of harm. Yet from a legal perspective, the patient’s guardian has entered a contractual agreement for which he or she is responsible.
By definition, a contract is “an agreement between two or more persons which creates an obligation to do or not to do a particular thing. Its components are competent parties, subject matter, a legal consideration, mutuality of agreement, and mutuality of obligation.” The doctor-patient contract meets all of these requirements. Therefore, if 1 party (the parent) proves incompetent in meeting the obligation of the contract, the second party (the dentist) is no longer bound by it.
However, in the arena of health care, the contract between doctor and patient is complicated by ethics and morality. Does the need for a timely treatment conclusion transcend the classic obligation of a contractual agreement? If the orthodontist chooses to withhold the last phase of treatment and delay debanding until the fee is paid, thus placing the patient at elevated risk for decalcification, root resorption, and periodontal involvement, is he acting in the best interest of the patient? The orthodontist might not have violated his contractual agreement with the parent, but does he violate the ethical boundaries of a health practitioner?
Efficient office management might have mitigated this problem by addressing it at its onset. If the conditions of the contract could not be fulfilled, the family could have been offered viable treatment alternatives or the option to transfer elsewhere. The ADA Code of Ethics is clear in this regard: “Once a dentist has undertaken a course of treatment, the dentist should not discontinue treatment without giving the parent adequate notice and the opportunity to obtain the services of another dentist.”
Based on these considerations, one would infer that the treatment and the financial obligation are independent of one another from an ethical perspective. At this stage of treatment, the most ethical solution is to initiate a dialogue with the parent to explore a practical method of completing payment. If this effort is unproductive, debanding and retention should proceed, independent of the patient’s outstanding balance. The only final course of action would then be to pursue legal action to secure payment for services rendered.