DIFFICULT MORAL QUESTIONS

Question 76: May a dentist do costly work before patients’ insurance ends?

My professional work as a dentist sometimes raises an ethical problem concerning the treatment of patients whose insurance is about to end, usually because their employers are eliminating dental care from their benefits, but sometimes because the patient is opting out. In deciding on a course of treatment, can I take the insurance situation into account? Or is that dishonest, even when all the information required by the insurance company is fully and accurately stated? Here are two examples.

A female patient in her fifties had multiple amalgam fillings in several molars. None required immediate replacement, though crowning all those teeth would be desirable, and might eventually be necessary. Her insurance coverage included the full cost of amalgam fillings and fifty percent of the cost of crowns. Since it was ending, I pointed out to her that doing the crowns now would be comparatively economical and would forestall problems for many years to come. I would have given the same advice if she had been wealthy and asked for the best possible treatment. However, she was of moderate means. If she had either been without insurance or were going to continue to be insured, I would not have urged her to go ahead at once. But, since her insurance was ending, I told her what I thought was in her best interests, all things considered.

The other case concerns a very prosperous businessman in his late thirties. I had restored two adjacent teeth in January, and when he returned in July he reported being bothered by a good deal of sensitivity to heat and cold in both. Examination did not reveal an abscess. Ordinarily my policy in such cases is conservative: Wait and see whether the sensitivity clears up or an abscess develops. I began to tell him what symptoms to watch for, but he explained that he was opting out of dental coverage as of the end of August, and asked me about the chances of an abscess developing and what would have to be done if it did. I told him that in roughly half the cases like his, an abscess will develop requiring root canal therapy and further restoration in at least one tooth. I went on to explain why I take a conservative approach. He had nothing to lose in waiting to see if an abscess develops, but unnecessary root canal therapy might be unsuccessful, and then one or both teeth would have to be extracted, which would be a great loss. He asked whether doing the root canals was likely to have a bad outcome in his case, and I had to admit it was not. Given this information, he said he liked the odds and insisted that I do root canal therapy on both teeth at once. Against my better judgment, I did. Fortunately, the outcome seems to be good.

Analysis:

This question calls for the derivation of specific norms. Provided all the information required by the insurer is truthfully supplied, it is not inherently wrong when making decisions about treatment to take into account that a patient’s insurance coverage will begin or end. Even when patients desire it, however, dentists, like other health care professionals, should never do anything they judge to be unreasonable, and it is unjust to accept an insurance payment for work one considered it unreasonable to do.

The reply could be along the following lines:

Adults bear the primary responsibility for their own health care, including dental care. The role of the dentist, like other health care professionals, is to help people fulfill their responsibility to care for themselves. In view of their other legitimate interests and limited resources, people often set reasonable limits on how far they will go in pursuing or promoting their health. You must abide by the limits a patient sets insofar as you believe them reasonable, either because you can see that they are or because the patient is trustworthy. In practicing your profession, however, you should fulfill a commitment to promote dental health by using sound technical means, and so should never do anything you believe inappropriate or technically bad, even if an unreasonable patient desires it.

In setting premiums and administering policies, insurance companies no doubt take into account that people whose dental coverage will soon end and their dentists sometimes make decisions about treatment influenced by that prospect. Hence, when all the information required by the insurance company is fully and accurately stated, I see nothing inherently wrong in taking the insurance situation into account. That can be wrong, however, if it leads to a decision that, all things considered, is unreasonable. Moreover, when a decision is unreasonable, accepting the insurance payment is unfair, for, while paying unreasonable claims is a cost of doing business that insurance companies pass on to those who pay the premiums, the latter bear a burden unreasonably imposed by those who receive payment on unreasonable claims, and thus suffer an injustice similar to having to help bear the cost of fraudulent claims.

Regarding the first case you describe—crowning molars restored with multiple amalgam fillings that did not require immediate replacement—you suggest as a standard what you would have advised the woman had she been wealthy and wanted the best possible treatment. That might not be an appropriate standard, however, since wealthy people sometimes desire more health care than is reasonable.

Your usual policy, which seems to me sounder, apparently is to provide every patient with good treatment within the limits he or she reasonably sets. On this basis, given the discrepancy between the insurance’s full coverage for amalgam fillings and its fifty percent coverage for crowns, you would not recommend crowns if this patient’s coverage were continuing, since that treatment is not urgent, but instead would assume it reasonable that the patient make do with the existing fillings. With her insurance coverage ending, however, it might well be reasonable for her to invest now in the crowns instead of waiting until they become necessary. So, it seems to me your advice to her was sound from both the technical and the moral points of view.

In the second case—root canal therapy on two sensitive teeth of a very prosperous young man who was ending his dental insurance—your usual policy would have been to avoid treatment that might be unnecessary and could even be seriously harmful. Making an exception in this case meant taking a very significant risk of doing unnecessary root canal therapy on at least one tooth and, supposing it unnecessary, a small chance of the patient’s losing one or both teeth when otherwise he would not have lost them. In this case you should have followed your better judgment rather than the patient’s wishes, and, in my opinion, complying was doubly wrong.

First, in the perspective of the good to which you are committed—namely, the patient’s dental health—the young man’s decision to proceed with possibly unnecessary root canal therapy, accepting a small chance of a bad outcome, was unreasonable. Of course, he had a reason. He was opting out of his insurance yet wanted it to pay for the work instead of risking having to pay for it himself. But I think that, being very prosperous, he should have avoided the possibly unnecessary root canal therapy and the risk of losing the teeth. You apparently agree, since you say you proceeded against your better judgment.

Second, carrying out the decision to do the root canal therapy at once did not reduce its cost, but simply shifted it from the young man to the group of people and/or employers whose premiums make it profitable—or, at least, possible—for the insurance company to provide dental coverage despite such cost shifting. Since the purpose of insurance is to spread risks individuals cannot reasonably accept among a large group, policy holders should not seek insurance payments to avoid taking risks they ought to accept. Thus, the young man’s cost shifting was unfair, and the injustice was the greater inasmuch as he was very prosperous. Since the payment you received belongs by right to those who paid the premiums, you have money you should not have and ought to make restitution. Must you reimburse the insurance company for the full amount you received? Perhaps, but not necessarily. The young man also should make restitution, though he probably will not. In any case, you must do what is fair, considering all things as they now are (see LCL, 444–58).

Someone might object that, since the sensitivity in the two teeth was caused by necessary work that had been covered by the insurance, it was only fair that root canal therapy to eliminate that sensitivity be carried out before the insurance terminated. That argument would be sound if it had been reasonable for the young man to insist on having the root canal therapy at once. However, as has been argued, the reasonable option would have been to wait and see whether the therapy proved necessary.

Nevertheless, in some clinically similar cases, doing root canal therapy could be reasonable and accepting the insurance payment fair. First, suppose a patient without insurance had a similar problem, was about to spend a year in a foreign country where dental care is very poor, and wanted you to do the therapy so that the work would not be botched. Clearly, that request would be reasonable, and you would rightly make an exception to your usual, conservative policy. Next, suppose a situation similar to the first, except that the patient’s dental insurance would terminate when he or she went abroad. The request would be no less reasonable, the exception no less justified, and the insurance payment fairly accepted. Finally, then, suppose a patient with the same dental problem who was going to lose his or her insurance coverage due to unemployment or inability to pay the premiums. If he or she had little prospect of obtaining root canal therapy when it might be needed, the request that you do it at once also would be reasonable, and so you could accept the insurance payment without unfairness to those whose premiums would cover the cost.

Even in this last case, though, you would provide better health care for your impoverished patient by adhering to your usual policy, promising to do the root canal therapy if it became necessary, and deferring payment until the patient could afford to pay. Assuming the risk—perhaps virtual certainty—of never being paid would be the merciful thing to do. If you could afford it without slighting some other obligation, that might well be your duty as a Christian, since mercy is the justice of the kingdom.