Certainly, the responsibilities of the dental hygienist include all of these and more. Social responsibility is a broad term that encompasses professionalism, personal and professional ethics, and the role of a profession in the context of the greater society.¹ It includes the concepts of a person’s right to health care, the profession’s obligation to raise the “dental IQ” of the community, and ensuring the health and well-being of the public. In this chapter, by necessity, more questions are asked than answered, but the stage is set for critical thinking and further discussion about individual and collective hygienists’ roles, values, and beliefs. The dental hygienist is encouraged to share thoughts and to discuss personal answers and ideas with colleagues.

Professional Ethics

A term often equated with social responsibility is ethics, commonly defined as the general science of right and wrong conduct.² Add to this the concept of moral action, and discussions emerge regarding which moral principles should govern a particular action. So intertwined and abstract is this concept that the terms ethics and morals are often used interchangeably.³

Professional ethics is the code by which the profession regulates actions and sets standards for its members, with the recognition that professionals are accountable for their actions.⁴ This code serves as a guide to the profession to ensure a high standard of competency, to strengthen the relationships among its members, and to promote the welfare of the entire community.⁵ The Code of Ethics of the American Dental Hygienists’ Association (ADHA) provides this guidance for the dental hygiene profession.

By virtue of the education, the written and clinical board examinations, and subsequent state licensure, dental hygiene is a profession, and dental hygienists are professionals and thus are required to make choices in practice that necessitate ethical decision making. Disagreements occasionally arise from different interpretations of the “proper” roles, responsibilities, and level of decision making of professionals involved in patients’ oral care.⁶ Often, these discussions take precedence over and are counterproductive to the larger issues of serving the needs of the public. Examples include whether dental hygienists should be able to (1) determine which teeth would benefit from sealant placement and (2) practice unsupervised in public health settings.

The Code of Ethics and Standards of Professional Conduct, adopted by the American Association of Public Health Dentistry, provides guidance for dental public health professionals through six basic principles, which may be summarized as follows:

Dental public health professionals have the following responsibilities:

1. Inform individuals and community organizations about health issues and options available for correcting oral health problems and inequities; facilitate health care decisions; ensure individual patient confidentiality; and respect individual and community customs, beliefs, and other cultural variations (autonomy).

2. Provide individual and community services in a socially responsible manner while maintaining respect for the value of the services received and conservation of individual, private, and public resources (nonmaleficence).

3. Provide the best care possible, but with the constraint that care should be equitable, that is, the best possible care that helps the largest number of people for the longest period of time (beneficence).

4. Not engage in acts of discrimination; but rather, promote policies that ensure equitable distribution of available resources and ensure that spokespersons for the public are included in the health policy development process (fairness).

5. Abide by their written, verbal, direct, and implied agreements; respects copyrights; and does not engage in activity in which there is real, or potential for, appearance of conflict of interest (truthfulness).

6. Participate in professional and community meetings; share knowledge and skills with colleagues and public; and recognize an obligation to protect the public (professionalism).⁷

Another set of debates arises in the attempt to define the term public, for instance:

• Does the word mean only those individuals who seek dental care? Are they the only ones the dental profession has “responsibility” for?

• What is the responsibility of the dental hygienist to the broader group of “public,” which includes people without access to oral health care services, culturally diverse populations, and people with special health care needs?

• Do people have a right to receive quality dental health care at a cost they can afford?

• What is a fair, or just, distribution of limited dental health care resources?

It is imperative that these questions be seriously considered because the dental hygiene profession’s commitment to ethical conduct is the foundation of society’s trust and confidence.⁸

This ethical conduct is not confined to a particular practice setting. “Ethical leadership” is knowing one’s core values and having to live them in all aspects of life in serving the common good.⁹ This encourages dental hygienists to be involved in their communities.

A System in Crisis

These questions, to which answers are as diverse as populations themselves, point to the need for a broader look at the general health care system in the United States. Many journals and newspapers report that health care in the nation is in a state of “crisis.” Although this statement is resounding in many private and public health circles, it is controversial in the face of the technologic advances in medicine and dentistry that have been responsible for improved health standards not only in the United States but also in many countries of the world. Technology has allowed delivery of advanced surgical and cosmetic dental services to one segment of the population even while significant barriers to accessing even preventive and basic restorative care still exist for others.¹⁰

It is also apparent that the health care crisis has been recognized, reported, discussed, and debated for more than 50 years, with minimal progress made. The Surgeon General’s report on oral health specifically quantifies the disparities in oral health status among underserved populations and the barriers many people face in obtaining care.¹¹ The health professions, including private- and public-delivery systems, national and state governments, public apathy, and a general lack of social responsibility on the part of society as a whole all have contributed to the failure of each attempt to render health care accessible to everyone. In one form or another, health reforms have been recommended for several decades with little success, and in most cases, oral health care services have not been included.

However, with the passing of health care reform legislation (Patient Protection and Affordable Care Act) in March 2010, significant oral health provisions were included. A few of these provisions are listed in the following:

1. Through the new insurance plans, oral health benefits for children are mandated with no out-of-pocket costs for preventive services.

2. Oral health surveillance is to be improved in all states.

3. Grants to school-based health centers, including oral health services, are available.

4. An evidence-based public education campaign is established to promote oral health, including a focus on early childhood caries, prevention, oral health of pregnant women, and oral health of at-risk populations.

5. Grant funding for school-based sealant programs is increased.

6. An alternative dental provider demonstration project is established.

7. Training, workforce development, and loan repayment provisions are established.¹²

There are increased expectations of the public health system and as work begins to appropriate funding for these provisions, there will undoubtedly be questions as to what constitutes public health and what the minimum standards for delivery of services should be.¹³

Health Care: a Privilege or a Right?

Health Care as a Privilege

The crux of the debate is the question of whether health care, including oral health care, is a “right” or a “privilege.”¹⁴ Who is responsible for “health?”

Guiding Principles

Who Has a Right to Health Care?

• Should the person who smokes have access to the same level of health care as the nonsmoker?

• Should children who are not eligible for Medicaid and who are living in poverty have access to after-hours treatment for ear infections and prescriptions for antibiotics?

• Should the senior citizen on a fixed income have equal access to properly fitting dentures?

• Should the immigrant female of childbearing age have access to culturally appropriate examinations and treatment?

Depending on your answers, who is responsible for delivering the health care and who is responsible for paying for it? Many would argue that it should not be only private providers offering reduced fees or donating their services. Additional publicly funded programs with acceptable reimbursement rates and dollars sufficient to serve the needs of the population are also needed. The following questions relate to whose responsibility it is to provide health care services and to pay for them:

• Should taxes be increased to support these programs or incentives implemented to increase provider participation?

• What is the responsibility of the patient seeking care?

• Should access to health care be a privilege of productive members of society who have the ability to pay for that health care?

• Are rights automatic, or are they “earned” as a reward for being socially responsible?

What is the Role of Government in Paying for and assuring Services?

These questions have no clear answers, and they challenge the individual provider’s values and sense of social responsibility.

Health Care as a Right

The United States Constitution does not specifically guarantee a “right to health” because “health” is a dynamic, continually changing state, unique to each individual.¹⁵ One interpretation is that health and access to health care are not so much a legal right; rather, they are a “moral” right and as such, the obligation of society as a whole is to provide care in response to that right, with providers playing an important role.² “The duty to ensure basic oral health for all Americans is a shared duty that includes federal, state, community, public, and private responsibilities. The dental profession, as the moral community entrusted by society with knowledge and skill about oral health, has the duty to lead the effort to ensure access for all Americans.”¹⁶ Society, however, has not universally accepted that responsibility despite several key events that have attempted to highlight the relationship among individual rights, human dignity, and the human condition.¹⁷

In 1946, the Constitution of the World Health Organization (WHO) defined health as “a state of complete physical, mental, and social well-being” (see Chapter 1). This was reiterated in the Universal Declaration of Human Rights adopted by the United Nations General Assembly on December 10, 1948 (Article 25):

Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care.¹⁸

An amendment to the Public Health Service Act, passed by Congress in 1966, states that “promoting and assuring the highest level of health attainable for every person serves the nation’s best interests.”

The fundamental basis of human rights is the recognition of the equal worth and dignity of everyone and implies that individuals, institutions, and society as a whole should protect and promote health and should ensure that health is neither impaired nor at risk. When the health of people has been left solely to the current health services system, many population groups have been left without access to health care and with little or no constituency advocating for their right to that care. Increasingly, this system has not been able to keep pace with the number of uninsured patients, expanding populations, shifts in demographics, degradation of the environment, and changes in lifestyles and value systems. This discussion becomes pertinent in the field of dental public health, which focuses on the prevention of oral diseases and promotes population-based health activities to ensure the oral health of all people.

Policy Development

As mentioned in Chapter 1, “policy development” is one of the core functions of public health and is often intertwined with promotion of oral health activities. Policy may be achieved through formal decisions (as in a school district decision), rules (as with a state dental board), or legislation at the national, state, or local level. To be successful, all policy initiatives should involve collaborative efforts between partners and stakeholders, including professionals, community leaders, coalitions, and the public.

Understanding the policy-making process is crucial to serving the needs of the public. Policy is used to connect the results of community “assessment” to “assuring” the oral health needs of the public are addressed. Regardless of the level of policy desired, the order of procedures is nearly identical, as follows:

• Develop personal and professional relationships with policy and decision makers.

• Collaborate with partners to identify data needed.

• Assess and quantify oral health needs and existing resources (see Chapter 3).

• Share data with partners and identify possible strategies and solutions.

• In a succinct and clear manner, share data and desired solutions with policymakers.

• Be available to policymakers for questions at all stages of the process and to provide information and testimony.

• Thank the policymaker, regardless of the outcome and continue to maintain the relationship for future efforts. Consider supporting other health policy initiatives supported or sponsored by this policymaker that may not have an oral health focus.

Examples of formal decisions include a determination by a school district to participate in a school-based sealant program; a process to assure nursing home residents receive daily oral hygiene care; a decision by a large employer to offer dental benefits; and a community water board decision to fluoridate their drinking water. Examples of rules include temporary dental hygiene licenses for Mission of Mercy projects and work with migrant and seasonal farm workers; and a process to certify mobile dental practices serving elementary schools.

In nearly all 50 states, state legislatures are bicameral (two houses). Nebraska is the only state currently with a unicameral legislature. Policy initiatives become “bills” and must pass both houses before going to the governor. Most state legislatures meet annually for a specified number of days, whereas other states meet every other year. Figure 9-1 is an illustration of how an idea (bill) becomes policy (/>

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