It was not very long ago that I thought that ethical dilemmas presented themselves only infrequently at my dental office. After all, it had been a long time since any patient asked me to change the date of treatment on an insurance form, or a dental supplier had made a billing error in my favor. Besides, I thought, I had a very structured and proper education, having attended religious schools from the first grade right up until graduation from college. I felt that my moral compass was firmly set toward justice, fairness and the American way and I did not have to take an ethics course to demonstrate what was right and what was wrong.

This past Monday morning, one of our receptionists, a woman who has been with us for a long time, brought three charts to my attention. Each of the three patients, over the previous weekend, had been attended to by a doctor from another practice with which we share call. One of the patients was a child who had experienced dental pain and apparently had an abscessed tooth. The covering doctor had prescribed an antibiotic and pain medication which proved to be the appropriate treatment. I wanted to see this patient that day, on Monday.

"Do we have to call them?" asked the receptionist. "They’re a collection problem and they haven’t been in here for over a year."

I understood her frustration. We were probably going to have to wait long and try hard to be compensated for our care. But I was concerned that she had misinterpreted our insistence on sound business practice, and presumed I would not see the patient until the balance was paid. She did not differentiate between an emergency, an urgent and an elective visit. I do not remember ever discussing this with my staff. Maybe I assumed they would realize the difference. The truth is, however, that I never gave it any thought. But these are the risks that health professionals take when developing business-office policy.

I told the receptionist that the child was still our patient since we had not dismissed him from the practice. We could have acted on that opportunity at any time over the past year by notifying the family in writing and offering to provide a month of emergency coverage, allowing them this reasonable time to find a new dentist. But we did not do that. It was now our obligation to see the patient regardless of financial history. It would be abandonment to refuse treatment now.

All this got me to thinking about another frequently misunderstood area of professional conduct: the transference of patient records. How many times have you heard the story of a fellow dentist, perhaps a colleague and respected member of the dental community, refusing to forward radiographs because "the patient hasn’t paid his balance."? I have heard it many times and as recently as a month ago. Well, this is where "sound fiscal policy" comes up against the "welfare of the patient." It may be frustrating. It may be galling. But just as function takes priority over esthetics, the patient’s welfare must take precedence over business considerations. The feelings that these circumstances can generate are quite upsetting and it is easy to understand how some practitioners might make an improper decision. When a patient requests that records be forwarded there is really no excuse not to promptly comply. For our protection, we should always obtain written permission from the patient or parent prior to forwarding radiographs and records, especially if the records contain information of a personal nature such as sexual preference, chemical dependency or HIV seropositivity. The records should be copied and forwarded at no cost, or for a nominal fee. A delay in transferring the patient’s records could adversely affect the oral health of the patient, and further, compelling the new dentist to take new radiographs will result in unnecessary radiation exposure to the patient and additional cost. It is also our responsibility to protect the privacy of the patient during the transference.

One of the points that these two examples illustrate is that ethical dilemmas occur with almost daily frequency in the dental setting. Most of the time they are subtle. It is easy to make an improper decision. It does not make any of us a scoundrel. But by adhering to our principles with all of the minor difficulties that challenge us everyday, we will have built the strength of character to overcome the greater temptations that unexpectedly knock at our door.

An additional point that surfaces is the fact that the dental staff has a lot to do with many of these situations. Communication with staff about our feelings and obligations would reduce misunderstanding and eliminate many problems. The time for discussion is before problems occur so as to spare the embarrassment of an individual. It might be the topic of a staff meeting.

As a member of the American Dental Association we have all agreed to be guided in our professional capacity by the ADA’s Principles of Ethics. These principles or standards are written with the welfare of the patient given the highest priority. In return for agreeing to abide by these principles society grants special favors upon the dental profession, such as self-regulation.

One of the most telling statements of how the leaders of the American Dental Association feel about the membership of the dental profession would make the member of any profession proud were it applied to them: "The Association believes that dentists should possess not only knowledge, skill and technical competence but also those traits of character that foster adherence to ethical principles. Qualities of compassion, kindness, integrity, fairness and charity complement the ethical practice of dentistry and help define the true professional. The ethical dentist strives to do that which is right and good." rjg