Q I recently saw a patient who requested that my treatment consist of only those procedures covered by his insurance. I have been hearing this request more and more frequently and am not sure how to respond. What are the ethical issues raised by honoring such a request?A Among the principles enumerated in the American Dental Association Principles of Ethics and Code of Professional Conduct1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar (ADA Code), Section 1, Principle of Patient Autonomy (“self-governance”), best reflects the idea of treating others as we would want to be treated. As dentists, this is what we all want and expect with regard to our own treatment choices. To ensure that we respect the autonomy of our patients, dentists must educate them about any proposed treatment. We need to discuss the risks and benefits of and alternatives to a particular treatment, as well as the risks and benefits of refusing such treatment “in a manner that allows the patient to become involved in treatment decisions.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar As part of that discussion, we need to explain how a recommended treatment could prevent the need for additional treatment in the future. This will help the patient make a better, more informed decision.Another aspect of informing your patient may include an explanation of a defined benefit plan. The term “defined benefit” means that the patient's employer purchased coverage that will pay up to a specific amount for a given procedure. Insurance, in contrast to defined benefits, deals with uncertainties. For you to base your treatment recommendations on the amount that the patient will be reimbursed may not fall within the bounds of accepted treatment, as required under Section 1 of the ADA Code. Although the patient's concerns about finances are important, the Code asserts that “professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Accomplishing the patient's goals while meeting the requirement to act within the bounds of accepted treatment requires a frank and balanced discussion with your patient.Section 2, Principle of Nonmal- eficence (“do no harm”), obligates dentists to “refrain from harming the patient.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Consequently, it is essential that the treatment you are recommending be based on your “keeping knowledge and skills current”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar rather than on what will be covered by the patient's dental plan. This does not mean that you disregard the patient's concerns, but it does mean that you need to discuss with him the reasons for your proposed course of action, even if it may not be covered by the patient's dental plan.As a corollary, Section 3, Principle of Beneficence (“do good”), reflects the dentist's “duty to promote the patient's welfare.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar The key to satisfying this duty 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.1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle ScholarSection 3 also states that “[d]entists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare first.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle ScholarAdhering to the ADA Code requires us to factor in the patient's expressed financial needs and wishes, but this does not require the dentist to act outside of that which he or she believes to be clinically appropriate. By having a frank discussion with the patient about the reasons for your treatment recommendations and listening to him express his goals and needs, you are respecting the patient's autonomy (Section 1), causing no harm (Section 2) and promoting the patient's welfare (Section 3).1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle ScholarFinally, according to Section 5, Principle of Veracity (“truthfulness”),1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar the dentist “has a duty to communicate truthfully.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar By adhering to this Principle, you may be able to convey your desire to do what is best for the patient regarding his overall oral health care needs. You are “respecting the position of trust inherent in the dentist-patient relationship.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar I prefer to treat patients who place their trust in me because we generally share the same goals. As dental professionals, our primary objective should be care in the patient's best interests.Part of our job as professionals is to educate our patients about the best treatment we can provide. If patients in your community continue to make treatment decisions on the basis of their defined benefit plans, you might consider taking the time to speak to local employers about your concerns regarding the patients you treat. Dentistry will be better for it, and you will be serving your patients, community and profession. Q I recently saw a patient who requested that my treatment consist of only those procedures covered by his insurance. I have been hearing this request more and more frequently and am not sure how to respond. What are the ethical issues raised by honoring such a request? A Among the principles enumerated in the American Dental Association Principles of Ethics and Code of Professional Conduct1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar (ADA Code), Section 1, Principle of Patient Autonomy (“self-governance”), best reflects the idea of treating others as we would want to be treated. As dentists, this is what we all want and expect with regard to our own treatment choices. To ensure that we respect the autonomy of our patients, dentists must educate them about any proposed treatment. We need to discuss the risks and benefits of and alternatives to a particular treatment, as well as the risks and benefits of refusing such treatment “in a manner that allows the patient to become involved in treatment decisions.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar As part of that discussion, we need to explain how a recommended treatment could prevent the need for additional treatment in the future. This will help the patient make a better, more informed decision. Another aspect of informing your patient may include an explanation of a defined benefit plan. The term “defined benefit” means that the patient's employer purchased coverage that will pay up to a specific amount for a given procedure. Insurance, in contrast to defined benefits, deals with uncertainties. For you to base your treatment recommendations on the amount that the patient will be reimbursed may not fall within the bounds of accepted treatment, as required under Section 1 of the ADA Code. Although the patient's concerns about finances are important, the Code asserts that “professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Accomplishing the patient's goals while meeting the requirement to act within the bounds of accepted treatment requires a frank and balanced discussion with your patient. Section 2, Principle of Nonmal- eficence (“do no harm”), obligates dentists to “refrain from harming the patient.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Consequently, it is essential that the treatment you are recommending be based on your “keeping knowledge and skills current”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar rather than on what will be covered by the patient's dental plan. This does not mean that you disregard the patient's concerns, but it does mean that you need to discuss with him the reasons for your proposed course of action, even if it may not be covered by the patient's dental plan. As a corollary, Section 3, Principle of Beneficence (“do good”), reflects the dentist's “duty to promote the patient's welfare.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar The key to satisfying this duty 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.1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Section 3 also states that “[d]entists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare first.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Adhering to the ADA Code requires us to factor in the patient's expressed financial needs and wishes, but this does not require the dentist to act outside of that which he or she believes to be clinically appropriate. By having a frank discussion with the patient about the reasons for your treatment recommendations and listening to him express his goals and needs, you are respecting the patient's autonomy (Section 1), causing no harm (Section 2) and promoting the patient's welfare (Section 3).1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar Finally, according to Section 5, Principle of Veracity (“truthfulness”),1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar the dentist “has a duty to communicate truthfully.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar By adhering to this Principle, you may be able to convey your desire to do what is best for the patient regarding his overall oral health care needs. You are “respecting the position of trust inherent in the dentist-patient relationship.”1American Dental Association American Dental Association Principles of Ethics and Code of Professional Conduct, With Official Advisory Opinions Revised to April 2012.www.ada.org/sections/about/pdfs/code_of_ethics_2012.pdfGoogle Scholar I prefer to treat patients who place their trust in me because we generally share the same goals. As dental professionals, our primary objective should be care in the patient's best interests. Part of our job as professionals is to educate our patients about the best treatment we can provide. If patients in your community continue to make treatment decisions on the basis of their defined benefit plans, you might consider taking the time to speak to local employers about your concerns regarding the patients you treat. Dentistry will be better for it, and you will be serving your patients, community and profession.