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Ethical Dilemma: Where Do the Business Person and the Philanthropist Meet? Dr. Beverly A. Largent, DMD

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A harried mom is in your waiting room with two children in tow. One child, about 18 months, is propped on her mom's left hip. The other, about four years old, is holding his mom's right hand. It's 2:30 p.m. and the mom is frantic to get help for her son before she has to pick up her older son from school in an hour.

The child is clearly in distress and appears to have stopped crying recently. You observe swelling on the right side of the child's face. You know there's a mouth-full of trouble and the child is in pain. The reason you're up front is your receptionist needs you to hear the mother's hardship case. She has no insurance, she says. She has no means to pay today (which likely means never). Please help her boy today, she implores.

Three other moms are in the waiting room with their children. The drama unfolding at your receptionist's desk is far more interesting than the magazines on their laps or the Frozen DVD playing in the waiting room TV. They're all watching you and your staff interact with the recent arrivals.

Like you, they notice the designer bag slung on the mom's right shoulder. Like you, they notice the family is dressed OK, but nothing flashy. They might also see the baby is playing with a fist-full of keys, but only you notice the remote fob for a recent-model imported car.

You want to bring the mother back so you can speak with her out of earshot of those in the waiting room. But the closer she is to your exam rooms, the more difficult it will be to decline care to her child.

Nonetheless, you don't want to have the conversation in the open for many reasons — not the least of which is two of the three families waiting for appointments are receiving some type of payment assistance.

A child is in pain. The mother has no means for payment.

If you treat children and practice in a socio-economically varied community, you're likely familiar with the preceding scenario. Depending on your practice and patient mix, similar scenes featuring children or adults in distress can play out in your office monthly, weekly or even daily.

As dentists and dental professionals, we are caregivers first. It is our duty to do our best to provide care to those who need it when they need it. The vast majority of us get into this profession because we want to help people. However, because most of us also operate in small businesses, we must be profitable. We must generate revenue sufficient to invest in our people and facilities to provide care to those who pay fair treatment fees for quality care. We cannot help anyone if we don't maintain a solid business.

How do we find that balance between the desire to care and the need to be profitable? Where does the compassionate person end and the businessperson begin? The answers to these questions are personal and vary from practitioner to practitioner. Here are some suggestions to consider for helping manage expectations among your staff, and current and potential patients.

Do the math

If the economic downturn did anything, it made us more mindful of the bottom line — down to the last prophy cup, probe and bib. While some regions have rebounded better than others, ask yourself these questions:
  1. How often do hardship cases present themselves? While they might not be as dramatic as an in-office plea for service, no-show rates and delinquent payments can be indicators of the level or hardship cases in your practice. How often do you get hardship calls? Do your best to gauge what your practice should expect and monitor it for peak and lag periods.
  2. Can we afford to provide hardship care? Established practices might be able to do more than one that recently moved to a community with significant startup debt. Again, this is a personal choice, but make a clear yes or no decision whether you'll accept hardship cases.
  3. How much are we willing to provide? Identify the kinds of services you'll provide and the maximum total dollar value of that care. Determine an annual, quarterly or monthly target and stick with it.

Have alternatives ready

Whether you decide to accept some level of hardship cases or not, or if you've reached a monthly maximum, identify alternatives you can provide to inquiring patients.

Is your practice located within a reasonable distance of a dental school or Federally Qualified Health Center (FQHC) or other nonprofit clinic? Do you know of colleagues in the community who take on hardship cases?

Compile a list of local dental and other community resources that you can provide to inquiring patients. Network with nonprofits in your community that offer any number of social services because it's not just dentistry.

It's not just dentistry

Regardless of one's views of the Affordable Care Act (ACA), coverage changes for the underserved will drive a sea change of treatment possibilities, especially for children. ACA's impact varies from state to state, but if you operate in a state making efforts to include dental care as part of ACA, become familiar with local information that you can provide.

Also, we know from experience that families facing hardship with unemployment, home loss, substance abuse or any other social challenge are more likely to undervalue or ignore oral health. Be familiar with your community's resources so families seeking hardship care can get help with other problems as well. Then, put it in writing.

Put it in writing

Whatever you choose for your practice, put your practice's policies in writing. At a minimum, the written policy should state whether you accept hardship cases. If you have limits on types of care, monthly expenditures, etc., include those in a policy document that you share with staff. Your reception staff and business manager should know, monitor and enforce hardship care limits.

If possible, have a written list of community resources that front desk staff can use with in-person and telephone inquiries. Developing and adjusting policies also could be a good staff team-building project if hardship inquiries are frequent and staff interest is high. Written policies will go a long way to help direct staff in uncomfortable situations.

Find other outlets for you and your staff

If caring is part of our DNA and business limitations prevent us from doing all we can in a practice setting, seek out other opportunities to get involved. Missions of Mercy operates across the United States, offering dental services to patients of all ages. Or, if you'd rather take a break from dentistry in your volunteer life, there are any number opportunities to make a difference in the lives of others.

Knowing you're doing all you can will help take out the sting you might feel when telling that caller, "No, I'm sorry we can't help you here, but I can give you information on who can help today."

There are many good causes in our communities and on the national and international levels. For me, I wanted to make a difference in my community and nationwide. Locally and in Kentucky, I serve as a board member of the Paducah Head Start. Twice a year, I examine, X-rays as necessary, provide cleanings, fluoride treatment and restorative services on all children in the local Head Start. My practice provides all preventive services for these children no matter their ability to pay, and we collect fees on Medicaid children only. We become their dental home.

On the state level, I serve on the Kentucky Medicaid workgroup, and have testified before the Kentucky Secretary of Health and Human Services, and will do so again in the spring.

Nationally, I joined the Board of Healthy Smiles, Healthy Children: The Foundation of the American Academy of Pediatric Dentistry just as it was turning its attention to helping the underserved. It provides me a great outlet for putting my local experience to work in a way that makes a national difference. At the same time, I can take what I learn nationally and apply it back home in Kentucky.

Where the businessperson and philanthropist meet

Success with cases like the one described in the opening scenario is where the businessperson and the philanthropist meet. It would be easy to judge the mom and question her priorities: nice bag, nice car and decent clothes. But, what if she was among the thousands of families that has found hardship and could likely bounce back?

The philanthropist wants to help the child in need and will do what he or she can to do so. The businessperson recognizes the child in need and sees the potential of the mom someday becoming a fee-paying patient.

Dr. Beverly A. Largent is a pediatric dentist practicing in Paducah, Kentucky, for 30 years. A past president of the American Academy of Pediatric Dentistry, Dr. Largent currently is president of AAPD's foundation, Healthy Smiles, Healthy Children (HSHC). During her tenure with HSHC, the Foundation has evolved into a national charity supporting community-based efforts providing dental homes for children whose families cannot afford dental care. Since 2010, HSHC has helped more than 118,000 children through more than $1.8 million in grants to 48 organizations.

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September 2025
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