The cases in the previous three chapters posed problems in which a dentist faced a conflict between following the principle of beneficence (doing what would appear to do the most good) and following a principle such as remaining faithful to a commitment or promise, respecting autonomy, or telling the truth. These conflicts have generally arisen between individual dentists and their patients.
A similar moral tension arises at the social and public policy level. The principle of beneficence is often applied in an attempt to resolve such conflicts. As we saw in chapter 6, utilitarian ethics strives to do as much good as possible. When more than one person’s welfare is involved, this means producing the greatest good in aggregate—taking into account the welfare of everyone affected.
However, just as there is sometimes a moral doubt that it is always ethical to do what will produce the most good when one patient is involved, at the societal level there is sometimes doubt that the morally right allocation of resources is to arrange them so that they produce as much good in aggregate as possible. Those who do not automatically accept that the aggregate good should be maximized believe that an additional moral principle must come into play—the principle of justice.
Justice is a moral notion with a very long history. According to Aristotle, justice means giving everyone his or her due.1 Equals are to be treated equally, and unequals are to be treated unequally. Aristotle recognized, however, that it can be very difficult to determine what counts as morally relevant. The need for dental restorations normally would seem to be relevant when the distribution of dental services is being decided; race and sex seem irrelevant. Between these obvious extremes are differences that may be much more controversial: income, age, location of residence, and whether dental needs are brought on by patients’ voluntary lifestyle choices. Whether these are morally legitimate grounds for deciding who gets care is the problem explored in the cases in this chapter.
The general problem posed by the principle of justice is what should happen when there are not enough resources for everyone—not enough dentists, dental equipment, or funds to pay for dentistry, for example. One possibility would be to give every patient an equal amount, but that would mean giving equal amounts of dental service to those who need extensive services and those who need none. Surely that is not the right answer. A pure utilitarian would arrange the distribution so that the greatest amount of good is done in aggregate. That also can be controversial. The amount of good is usually measured by multiplying the intensity of the benefit by the length of time that it will last. This could mean that very old people would get low priority because, for example, even if they could benefit greatly from a dental restoration, the length of time the restoration lasts would be limited by the time the patient lives. Likewise, if some dental services are costly and time-consuming and other services (in other patients) can produce the same amount of good for less money and time, trying to maximize the amount of good done would mean purposely concentrating on those patients who could be benefited cheaply.
The principle of justice holds that sometimes the way in which the benefit is distributed counts morally. “To each according to his or her need” is an example of a justice-based way of distributing scarce resources. To each according to merit, ability to pay, or any other criterion would be other versions of justice-based allocations. The cases in this chapter pose problems of how dentists, as individuals or collectively, should allocate their services, time, and benefits. The cases in the first section deal with societal allocation questions, which are sometimes called macroallocations. Those in the second section will look at allocation questions facing individual dentists, or microallocations.
The most general allocation questions involve what portion of total societal resources should be devoted to dentistry. One of the more intriguing problems in professional ethics has to do with what role members of a profession ought to play in deciding what portion of a society’s resources should go to services in their field. They are obviously the real experts in dentistry; however, they might well place uniquely high value on the good that their field can provide. Dentists probably place unusually high value on caries-free teeth and well-functioning dentitions, just as lawyers might place high value on legal protection, accountants on impeccable account books, and the clergy on the spiritual life. In a world of scarce resources where no one can have all of every good thing in life, we can assume that a less-than-ideal level in each area makes sense. If the experts in each sphere uniquely value their own area, they can be expected to make somewhat biased decisions about how much of society’s resources should be spent in their sphere. Thus it would not be surprising if dentists as a group believed more resources should go to dentistry, physicians believed that more should go to medicine, and so forth.
At the societal level, then, decisions must be made about how to spread the resources available to dentistry among the many dental needs. Dentists with different agendas are likely to disagree. Pediatric dentists may make a case for protecting children’s teeth; geriatric dentists may likewise make a case for the needs of the elderly. Public health dentists may advocate prevention while restorative dentists may emphasize relieving the suffering of patients who already need interventions. The first case in this section looks at how public health dentistry might allocate a limited budget for dental sealants.
In 1983 the National Institutes of Health created a consensus development panel on dental sealants as part of its ongoing project to assemble panels of experts to review matters of important public scientific controversy. The panel was made up of some of the country’s leading academic and clinical dentists, as well as a dental technologist, a lawyer who was a children’s health advocate, and a bioethicist. They were to assess the safety and effectiveness of the use of dental sealants and to make recommendations about their use.2
The panel had no difficulty concluding that sealants were generally safe and effective and that they were best used on children soon after the eruption of the permanent teeth. A controversy emerged, however, at an unexpected point in the panel’s deliberations.
After recommending that public health dental officers give high priority to ensuring that the children in their communities had their teeth sealed, the question arose about what should be done when not enough funds were available to seal the teeth of all of the children in a given county. In particular, some county dental health programs served a number of communities, some of which had publicly fluoridated water while others did not.
For technical reasons, children growing up in communities with a fluoridated water supply can make more efficient use of dental sealants. Because fluoride is especially effective in reducing caries on proximal surfaces, fewer Class 2 restorations will have to be placed and consequently fewer sealants will be destroyed. Thus, if a county public health dental officer wanted to use a limited preventive dentistry budget with maximum effficiency, he or she would target communities where children drink fluoridated water.
The panel at this point faced a serious moral dilemma. Would it be fair to purposely give the advantage of sealants preferentially to children in communities where the water supply was fluoridated? It is surely not the fault of the children in the communities without fluoridated water that their teeth do not get fluoride protection. Moreover, some of those children actually get fluoride through application by their dentist. Still, it would be terribly inefficient for a school-based program to identify those children who are treated privately and to seal only their teeth.
Should the dental sealant panel recommend that limited funds for public sealant programs go to the children who can be treated most efficiently? Should these children get the funds even though they are already better protected (for proximal caries) and even though it is not the fault of the other children that they do not have fluoridated water supplies? Or do all children under the jurisdiction of the county public health dental officer have rights of access that should not depend on their parents’ decisions about their water? If so, because it is impossible to seal all of the children’s teeth, which children should get priority: those with the greatest economic need, those with the worst teeth, or those selected at random?
The panel faced an interesting problem. If they wanted to prevent the most decay per dollar invested—if they wanted the limited funds used as efficiently as possible—they would purposely discriminate against patients without community-fluoridated water supplies. A similar problem arises in many other health allocation decisions. For example, it is often more efficient to treat middle-class patients than low-income patients. Sometimes it might be more efficient to treat a certain gender, race, ethnic group, or age group. When the specific facts of the situation make discrimination more efficient in terms of improving overall community health statistics, those who accept social utilitarianism—that is, those who apply only the principles of beneficence and nonmaleficence—will intentionally choose the most efficient allocation, even though it is discriminatory. The dentists on the panel who were utilitarian favored giving priority to the children in the community-based fluoridation programs. Other members of the panel, including the patient’s rights–oriented attorney and the bioethicist, insisted that the principle of justice had to be considered. They argued that the principle of justice would require a policy in which all children had an equal chance at getting the sealants—even though it was less efficient and fewer caries would be prevented.
The problem of allocating scarce dental resources among patients with a need for services often arises in community dental programs designed for low-income patients. In the following case, there is an increasing number of needy patients. The only way to serve them is to scale back the services. The alternative is to refuse to accept new patients.
The dental health director of a large western city is in charge of several programs that provide dental service to low-income people. Although his programs cannot offer complete comprehensive care, they provide emergency service to anyone in need; in many cases, basic restorative care also can be given. In addition, for some patients with substantial needs, treatment beyond the basic requirements is available.
The demand for dental services has been increasing because there are more patients who cannot afford to pay for care in the private sector. The director wonders what to do about the increased demand for services. Should he turn some people away to maintain his previous policy? Or should he scale back the scope of services offered to serve more people?
In this case, as in Case 46, there are not enough funds to provide the care that the dental health director desires. Unless more money becomes available, something must suffer. In this case, presumably all of the people who qualify for the program are financially needy (if they are not, then better screening probably is in order). One of the strategies that is contemplated is a time-tested principle of allocation: First come, first served. Those who entered the program early enough will continue to receive the full range of presently covered services. This is a principle that is often used when the scarce resources cannot be divided among those who need them. For example, it has been used for allocating scarce organs for transplant. Obviously, it accomplishes nothing to give each worthy heart transplant candidate half of a heart.
In the present case, however, it is possible to distribute the scarce resources so that all patients, existing and latecomers, could have part of their needs met. In one way or another, the city dental health director could limit the services so that those with the strongest claim receive the care.
If that strategy is chosen, someone must decide on what basis the care would be limited or what counts as a strong claim. The choice could be made on straight efficiency grounds—providing the services, whether basic restorative care or more complex procedures, that result in the largest benefits. That approach would most efficiently maximize the total good done, but some patients—for instance, the elderly—might not even get basic restoration if such treatment turned out to be inefficient in their cases.
Another approach would be to develop a list of services that all patients would receive regardless of when they entered the system and how efficient the service is in particular cases. For instance, the program could cover basic restorative procedures and extractions but not endodontics, periodontics, or fixed prosthodontics. Some people with considerable needs and perhaps even in severe pain who could be relieved efficiently with these more complex procedures might not get served. If some limits must be imposed, the basis could be first come, first served; maximum aggregate good; preference for basic over higher-tech care; or most acute, severe pain (even if the patient is inefficient to treat). Choosing to maximize the aggregate good based on social utility would be chosen by utilitarians; those who give priority to the principle of justice would either serve those who come into the program first or attempt to reduce the list of covered procedures to focus even more on the needs of the worst-off patients.
One of the factors often taken into account when deciding who should receive resources is age. In the medical literature, there is much debate about whether elderly patients should get lower priority.3,4 While one interpretation of the principle of justice would insist that the elderly receive equal treatment regardless of their age and the shorter time they will benefit from it, another interpretation of justice would permit treating the elderly differently on the grounds that they have already had a long life. The latter view is sometimes used to justify lowering the priority for elderly patients to receive major organ transplants. (Many people believe that a 90-year-old should not have the same priority as a younger person for a heart transplant.) On the other hand, most people believe that all individuals, regardless of age, have an equal claim to the relief of severe pain and discomfort, which is likely to be the objective of the limited list of services that is likely to survive the health director’s priority setting. If age is to be the basis for giving one of these groups preference over the other, we need to determine whether it is because of efficiency or because of fairness. The following case poses the problem of choosing between children and adults.
An eastern state has an annual dental Medicaid budget of $7.6 million. Of that amount, $5.1 million is allocated for children and $2.5 million is allocated for adults. Currently, comprehensive care is mandated for children, whereas funding for adults is almost exclusively for emergencies. A major problem of the Medicaid program is that access to care for children is very difficult despite the mandate for comprehensive care. This is because the state’s Medicaid fees are so low that it is difficult to find providers. In fact, this state’s fees are among the lowest in the country.
The program’s dental director was considering a way to get more providers for children. He could eliminate the adult program and transfer the money to the children’s program to raise the fees, making it easier to attract providers. He figured that he could probably get approval for the proposal if he decided to put it through. He considered the pros and cons of making this move.
The ideal solution to this problem for those specially committed to dentistry would be to appropriate more money for the dental Medicaid budget. In the real world, however, that might not be possible. Other people have other priorities. Whether or not those priorities are ethically defensible, the funds allocated for dentistry are likely to remain at less-than-ideal levels.
Assuming that additional funds are not forthcoming, what would be a fair solution to the problem? Some arguments for increasing the proportion allocated to children are based on efficiency, or maximizing the amount of good that can be done. Perhaps interventions done early enough will prevent greater harm in later years. They may establish beneficial patterns that would make the benefits of childhood dentistry large in comparison to the costs. Along this line of reasoning, if the $2.5 million spent on adults could do more good if it were spent on children, then the switch should be made. However, some interventions done for children may not be that efficient. Especially for interventions that affect primary teeth, the length of the benefit will be much shorter. Sealing primary teeth, for example, is not as efficient as sealing permanent teeth. If we opt for the straightforward effort to maximize the good, some children may actually lose.
Another basis for deciding this question is to ask what is fair, regardless of whether the maximum possible good is done. There are several possible answers to that question. Some would argue that fairness requires treating the worst-off patients regardless of whether they are children or adults and then readjusting the allocation based on what it takes to achieve that goal. If so, keep in mind that sometimes treating the worst-off patients may not be the most efficient use of resources. This would be a case of a direct conflict between efficiency and equity.
Some people have begun to calculate fair or equitable allocations by looking at how well off a person is over his or her lifetime rather than how well off he or she is at a given moment. From this perspective, an elderly person who has had good dentition all her life but is now experiencing moderate tooth mobility related to bone loss might be thought to be better off than a child whose immediate problem with caries is less severe, but who will have to live a long life with the problem. Regardless of how the question of age is settled, those committed to the principle of justice want to determine which patients are worst off and use the limited Medicaid funds tomeet those needs.
Age is one category that raises questions of justice; income is another. One place where this issue has arisen recently is in the use of live patients during the licensing board examinations for dental school graduates. The problem raised is that of exploitation. Is the use of health services to entice people to use their bodies for the good of society exploitative, or is it merely another way they can get needed dental care? The next case involves the use of live subjects for licensing exams.