Case: How Much Sacrifice

CASE: HOW MUCH DO WE OWE?

When Dr. Sharon Sullivan returned from lunch around 1:00, she saw a new patient in Operatory 2. "Who's in Operatory 2?" she asked her hygienist, Elizabeth Minowski. "I checked the day-list and I don't recognize her."

"That's Edith Blake. She's an emergency. She says she's been in pain for three or four days, but she obviously hasn't seen a dentist in a long time. Every quadrant has caries and perio involvement. She lives at the Transition Home, and someone there sent her over here."

"Where's the pain?" asked Dr. Sullivan.

"Upper left. 1saw a large lesion in #13, but there are several teeth with inflamed gingiva as well.She was squeezed in as an emergency before Mrs. Livingston at 1:00. I just got her in the chair and took a quick look when 1heard you come in. Do you want me to examine her and do a full record before you look at her?" asked the hygienist.

"No, Liz," said Dr. Sullivan. "I might as well see her myself right now, since Mrs. Livingston isn't here yet. But what do you mean, that they sent her over from the Transition Home? What's that?"

"The Salvation Army runs a home for women who are trying to get out of prostitution over on Third Street. Ithought you might have heard of it. Carolyn Elward was one of the supervisors there. She was a patient of ours before Dr. Bingley retired, although I don't remember seeing her since then. I don't know if she still works there or not. Anyway, Ms. Blake is a resident at the Transition Home. She says that her hall leader told her she should see a dentist when aspirin wasn't strong enough to control her pain, and someone said she should come here because she could walk over from the Home."

"Okay.When Mrs. Livingston gets here, have Jane explain to her that it might be a little wait because of a patient with an emergency problem," said Dr. Sullivan. "She's better waiting in the waiting room than in a chair because she gets so anxious once she's in an operatory." Then she went to meet Edith Blake.

"Hello, I'm Dr. Sharon Sullivan," Sharon said to Edith. "Ms. Minowski tells me that you've been having quite a bit of pain in the top left part of your mouth. Is that correct?'

"Yes, it's been hurting for three or four days, but this morning it got so bad that even aspirin wouldn't help it."

"How long is it since you've seen a dentist?" she asked, beginning her examination.

"It's a long time," said Ms. Blake. "It's since I was in high school." "How old are you now?" asked Dr. Sullivan. ''I'm twenty-six, so it's almost ten years, I guess."

"Well, I'm sorry to say that your teeth have some problems."

"I'm not surprised, I guess," said Edith. "I really didn't take good care of myself for quite a long time. I was on the street, if you know what I mean, and I didn't care very much about things like that. I really didn't care very much what happened to me at all, in fact, so taking care of my teeth wasn't much of a priority."

"I understand what you're saying," answered Sharon. "Ms. Minowski mentioned that you're staying at the Transition Home now. Has that helped you get a better hold of things?"

"Oh, yes," said Edith. "I feel safe there, and I'm even beginning to think it's worth taking care of myself. The counseling and the other girls who live there, and the girls who have completed the program and come back to help us, they have helped me a lot. They really understand what it's like to be on the street, and what it does to how you think about yourself. The Little Handbook they give you says the first goal for every girl is to restore your self-esteem, and I certainly need that."

"How long have you been living there?"

"I found out about it about three months ago and talked to them on the telephone. But it's not easy to get off the street; you can't just walk away. It took me until five weeks ago to get away. That's when I went there and they accepted me in their program," said Edith.

Meanwhile, Dr. Sullivan had completed her examination. Besides the deep cavity in the upper-left second bicuspid, which was the likely cause of Ms. Blake's pain, there were carious lesions in half a dozen other teeth and periodontal involvement at several sites as well, plus whatever else X-rays might show. At first look, it seemed likely that all of the teeth were salvageable, but Ms. Blake clearly needed a lot of dental work. Dr. Sullivan excused herself to see if Mrs. Livingston had arrived and ask Elizabeth Minowski to take some X-rays.

"Excuse me for asking, Sharon," said Elizabeth. "But have you talked to her about paying for this?"

"Actually, no, Liz," said Sharon. "I was so focused on getting the exam done before Mrs. Livingston got here that I haven't mentioned money."

"That's why I made a point of telling you she was from the Transition Home. I doubt she has any money to pay for a lot of dental care," said the hygienist.

"And you were trying to clue me in by mentioning the Home without actually saying she can't pay?"

“Yes.”

"Well, I appreciate the effort," said Sharon. "But I didn't get the hint. Mrs. Livingston still isn't here, so I'll talk to her about it. Would you take the X-rays in any case when I'm done speaking with her so we actually know what we are talking about?"

Sharon returned to the operatory and explained to Edith what she had found in her examination. ''I've asked Ms. Minowski to take some X-rays of your mouth when we are done talking here to make sure there aren't any further problems that I can't see. But even if there aren't, it would take three or four visits to deal with the cavities you have and give your teeth a proper cleaning and scaling. And then we would have to decide how much additional treatment you would need for the periodontic problems, especially if they are more serious than they appear right now."

"I don't have that kind of money," said Edith. "I told the woman who brought me in here that I didn't know if I could pay for this, but she said you wouldn't send me away in pain so I should talk it over with you. But you were so nice and talking with me that I forgot to say anything. I'm sorry."

"Well, I enjoyed talking to you, too," said Sharon, "and that's why I forgot to mention it also. But you really should get these problems attended to or you will have more bouts of pain, and maybe much worse ones than this. Do you have a job at the Home or somewhere? We could certainly arrange a long-term payment plan so you wouldn't have to pay a lot of money right away. I do that with many of my patients."

"At the Home, the work I do helps pay for my room and board. I only get twenty dollars a week for spending money from that. That's what I brought to pay for this appointment; I just got paid this morning. I hope it's enough. If I do well in the program, the Home will help me find a real job after three months. All the girls who have left the Home have left with real jobs, and the Home helps them find an apartment and they come back for counseling and to help the girls who are still there. But I won't be able to do that for two more months, or maybe more."

"I don't want to take your twenty dollars, Edith," said Sharon. "If you can stay for a while this afternoon, I will work around the other patients in my schedule and fill the big cavity in your upper second bicuspid because that probably is what is causing your pain. I don't have to charge you for that, if you will stay here so I can fit it in between my other patients."

'That is very kind of you, Doctor. You really should take some payment for that, even if it isn't close to enough. I really appreciate it," said Edith.

"But my concern is your other teeth," said Sharon. "You will be in here again in no time if they aren't attended to, and you need to have a good cleaning done, so you can begin taking proper care of them again."

"Well, I will start brushing them, like I am supposed to. But I really couldn't pay for a lot of appointments, and it isn't fair for you to have to do all that work for nothing. I think it will just have to wait until I get on my feet."

"I really don't think that would be the best thing for you," said Sharon. "Let me think about it. My next patient is here now. I will be back to work on that cavity as soon as I can. In the meantime, Ms. Minowski will be taking some X-rays."

How should we think about this case? Try the following:

1)Identify the alternatives—what options does Dr. Sullivan have?

2)Determine what is professionally at stake. In this step, we also want to take into account the considered judgment of others. That is, what would my professional colleagues suggest? Dr. Sullivan obviously must do what she has promised, but what about the conflict between her professional obligation to care and the financial health of her practice? How much do we owe?

3)Determine what is ethically at stake. Is Dr. Sullivan morally obligated to make a sacrifice for Edith? What about the distinct possibility that, given her previous lifestyle, Edith is HIV positive?

4)Determine: what ought to be done? What goals should Dr. Sullivan have in mind? This is clearly a case in which reasonable people are likely to disagree.

5)Finally, choose a course of action, recognizing that there is no formulaic way to know that we have indeed made the optimal choice.