Students who select the profession of dentistry give a variety of reasons for their choice.1–3 Among them are the ability to earn a good income, the prospect of independent employment, and the opportunity to serve the public. However, when they first set foot in a dental school, most of them know little about professions in general or dentistry in particular. Furthermore, what they do know is almost certainly more closely related to dentistry’s economic circumstances and working conditions than to any of its more esoteric aspects, such as the nature of the dentist-patient relationship.
It is not that money and how one earns it are not important or even crucial to choosing a career. However, these extrinsic considerations are but one aspect of the professional experience. It is at least as important to understand the scope of one’s obligations to patients, to self, to the profession, and to society at large. In addition, it is vital to know how the various roles played by private practice, academia, professional organizations, codes of ethics, and licensing boards are all essential components of the dental profession.
In this chapter, we first discuss the historical development of professions in order to better understand their current structure and function. Next, we discuss the special obligations that professionals have to the people they serve. This is followed by a presentation of the characteristics of professions, as related to their historical development. Finally, in order to promote a more complete understanding of the relationships between professions and society, we consider some recent critcism of traditional views of professions.
The etymologic roots of the word profession have left their mark on all of its derivatives. Its original Latin meaning was “to profess,” which signified one’s willingness to make a public declaration of something that was important—and what usually was important was religion. For example, Webster’s Third New International Dictionary first defined profess as the public act of taking religious vows. From that focused starting point, its meaning expanded to include open declarations of belief that are nonreligious. And for our purposes, “profession” also includes callings that require intensive preparation and high standards of achievement and that render a public service. Finally, however, its meaning has softened to include the less restrictive usage that many people give the term today: “a principal calling, vocation, or employment”4—in other words, almost anything that occupies most of one’s time.
In the 16th century, the term profession was used for the first time to denote the special occupations of medicine, law, the divinity, and (sometimes) the military. These were the so-called learned professions. However, much of the population used the term to refer to everything from barbering to blacksmithing.4 Thus, in at least one respect, not much has changed in the past four centuries. Nevertheless, over the years the restricted concept of profession has been the focus of a considerable body of literature that has attempted to define and characterize what professions are and how professionals ought to function.
From a developmental standpoint, it is clear that in the 16th century, professions were manned by members of the privileged class who had been educated in universities created many years before. In William F. May’s words,5 “‘having a profession’ provided a social location in life for the second, third, and fourth sons of aristocrats who, in a society committed to primogeniture, could not inherit portions of the estate that went exclusively to the eldest son, and yet who, as children of the aristocracy, should not have to work for a living and thus submit to the vulgarities of the marketplace. Thus the professions . . . provided the great families with an honorable social location for their surplus gentlemen.” It follows, therefore, that the respect bestowed upon professions flowed only in part from the education they required and the value of their services. More important, their status stemmed from the privileged births of their members.
From that powerful beginning, the character of the “elite professions” changed but slowly over the generations that followed. With the onset of the Renaissance and the development of the middle class, increasing numbers of people—especially in England—entered occupations that more and more resembled the professions of the wellborn. Hence, the newcomers, too, wanted to be looked upon as members of a profession rather than as tradesmen.
To achieve that goal required a lot of work over a long period of time, guided by effective organization. Members of the would-be professions banded together to form associations, or guilds—certainly with no help from the state or anyone else—whose function it was to ensure survival. Over the course of generations, they performed whatever tasks were necessary to establish their credibility. For example, it was essential that adequate training and credentialing were both available and required for aspiring professionals, together with a license to practice. With these safeguards to the public in place or in development, the associations might then acquire enough power to negotiate with the state for favorable competitive positions in the marketplace. Their goal, in other words, was to restrict the practice of their particular occupation to members of their group. They also understood that they would not be taken seriously unless they demonstrated that they could provide dedicated service, administered with a sense of integrity.
This was the pattern for the development of professions in England. It also served as the prototype for what happened in the United States.* In these two countries, each hopeful occupation launched its own process for gaining credibility and sanctuary in the marketplace. And when an occupation became “successful” in establishing its legitimacy, it gradually became known and referred to as a profession.
In the United States, dentistry’s attempts to be recognized as a profession moved ahead significantly in the 1830s,6 thanks in part to the financial panic of 1837 and the unstable economic climate of speculation that preceded it. Businesses went bankrupt, banks collapsed, and unemployment escalated wildly.7 Unlike in England, where people usually became dentists after lengthy apprenticeships and had done so since the 16th century,8,9 in America there was no well-established system. Many American dentists were quite competent, often as a result of apprenticeship training. Nevertheless, because people could convert from the plough or the workshop to the dental chair in a few short months—often in a few weeks—dentistry loomed as a golden opportunity for unemployed people of all sorts to generate income quickly.7 The collective competence level of the young profession soon plummeted, and concerns about the quality of care rose abruptly.
Although no national dental associations existed at that time, it was dentistry’s good fortune that leaders emerged to organize their colleagues, all in the public interest against unscrupulous practitioners who advocated unorthodox treatment and who advertised aggressively and effectively.6 In addition, influential practitioners turned their attention to three landmark ventures. One was to initiate a professional journal designed to “disseminate correct principles and expose error”10 ; it was called the American Journal of Dental Science and first appeared in 1839. Another effort was to establish schools specifically for the teaching of dentistry. In 1840, the world’s first dental school, the Baltimore College of Dental Surgery, was created. The third effort was to create professional organizations, and again in 1840, the American Society of Dental Surgeons, the first national dental society, was formed. Leaders in the field also considered lobbying for legislation that would regulate licensure, but the prevailing political climate of individualism delayed those efforts for decades.10 All these events are milestones in dentistry’s movement toward recognition as a profession. All of the professions recognized today have experienced comparable landmarks, and for all of them, the process has been painstakingly slow.
Differentiation of a profession from other occupational groups is a complex social process. It requires society’s acceptance of a special social status for the professional group. Assigning that status involves recognition of specialized knowledge not readily available to the general public and obtainable only through prolonged education. It also requires acknowledgment that the group has a special responsibility to promote the public interest and abide by a code of ethical conduct. Even after an occupation is widely regarded as a profession, the maturation process continues. In the United States, it was not until the late 1800s and early 1900s that the current economic prestige of the professions was established and their advantageous positions in the marketplace secure.11 These were important milestones because they represented the overturning of a political tradition in the United States that resisted restrictions on entrepreneurs about how goods and services ought to be provided. For example, during the Jacksonian period of the 1830s and 1840s, Congress actually repealed legislation giving monopolistic advantages to medicine and law that had been enforced since the colonial days. The result was that an individual could practice any livelihood he or she wanted. For bonesetters, herbalists, and grocers/ druggists, this was an open invitation to practice medicine. It took decades of political effort and appeal to the public interest before the earlier status quo was re-established.
In summary, from a developmental standpoint, a profession begins with the practice of a potentially distinctive body of expertise by a group of informally trained people. The expertise is viewed as having public value. The knowledge required of its practitioners expands with time, and during a long gestational interval, its members form organizations that promote their interests. In addition, they create systems for education, credentialing, and eventually licensure. The practitioners work to convince the public of their commitment and honor and of their ability to manage their problems and collegially maintain their discipline. The process is slow and untidy, but for the occupations that achieve their goal, the result is a rewarding career that serves important and highly valued roles in the public interest.
The process in general can be viewed as an unwritten pact with society, the basis of which is traditionally understood as follows: Professions are social institutions in that they provide services on behalf of the common good.12 In return, they are granted a certain degree of power and autonomy with respect to their standards of practice, how their practitioners are trained and admitted to practice, and how the behavior of their members is monitored.6,13 As long as society has confidence in the good will of the profession and believes it correctly serves the public interest, this arrangement is mutually advantageous.
There is one other point that should be made regarding the evolution of professions. Although reading about how occupations struggle to become professions helps us understand both their structure and their function, it can also be misleading. One gets the impression that after generations, maybe centuries, of hard work to become a profession, on some glorious day society formally grants the long-sought status. However, from the perspective of those who were in the midst of the struggles, nothing could be further from the truth. For example, in the 1830s, when the stage was being set for major advances in the professionalization of dentistry, those who practiced it already viewed themselves as members of a profession. They had no doubts at all. When dentists wrote or spoke about the challenges facing dentistry, the context of their concerns was their profession. Furthermore, when they took action to improve the quality of education or cope with irresponsible practitioners, they spoke of doing it to benefit their profession.11
The early 19th century dentists’ conviction that they were indeed professionals acknowledges their recognition of the evolving definition of a profession. The next section provides direction for an increased understanding of the meaning of that term, while indicating that its definition is by no means agreed upon by all.
The definition of profession given previously covers some aspects of professionalism but ignores others, including self-regulation and collegial discipline. In fact, there is no consensus about what a profession actually is.14
Consider, for example, the differences between the definition offered by the American College of Dentists (ACD) and the definition that appeared in Paul Starr’s book, The Social Transformation of American Medicine.11 The ACD15,16 defines a profession as: “[a]n occupation involving relatively long and specialized preparation on the level of higher education and governed by a special code of ethics.” By contrast, Starr, a respected sociologist of the professions, defines it as: “[a]n occupation that regulates itself through systematic, required training and collegial discipline; that has a base in technical, specialized knowledge, and that has a service rather than profit orientation, enshrined in its code of ethics.”
We find the Starr definition significantly more helpful. Although both definitions speak of the long and specialized education that is required, Starr’s definition also includes the service orientation and self-regulatory aspects of professions.
Starr also points out that the behavior of professionals is regulated by “collegial discipline.” Dentistry, for example, primarily functions through the self-restraint of individual practitioners. This is reinforced by the actions of associations* and the American Dental Association’s (ADA’s) Principles of Ethics and Code of Professional Conduct.17 With respect to the latter, we disagree with the ACD definition. Rather than possessing the authority of governance, codes of ethics serve mainly as guides for conduct. There is little that dental associations can do to punish noncompliance; in many cases, codes of ethics provide no controlling influence other than suspension of membership in the organization—license to practice remains intact. In extreme cases, discipline is managed with the legal sanctions available to the state dental boards and with the malpractice system. This topic is discussed in the section on collegial discipline.
In addition, only the Starr definition cites the orientation to service rather than profit. Neither definition, however, deals with the relationship that professionals have with their clients or patients. This relationship, which is often said to be fiduciary in nature, is arguably the most distinctive aspect of being a professional and therefore is considered next.
Lawyers have different obligations to their clients than physicians have to their patients or veterinarians have to theirs. Likewise, the obligations of accountants, psychologists, engineers, or journalists differ because the goals of each profession differ, as do the services they perform.
However, they share a common characteristic—the fiduciary relationship. (With regard to principles of ethics, the fiduciary relationship is based upon the principle of fidelity, as discussed in chapter 7.)
A fiduciary relationship is based on trust and confidence that commitments between parties will be honored18; it exists whenever a doctor and a patient establish a professional connection. Because the patient should be an active participant in the relationship, these commitments are a two-way street. However, given the unequal knowledge and skills of the two parties, it is especially important that the health care provider be worthy of that trust.19
In the context of a fiduciary relationship, trust has two elements.20 The first is competence. With dentistry in mind, patients expect dentists to be competent in executing their responsibility as oral health professionals.
The other element of trust transcends competence and moves to morality. The public trusts dentists to place their patients’ interests higher than their own.
During their training, dentists are perpetually preoccupied with becoming trustworthy in the first sense. The achievement of competence is a long process and, for many, a painful one weighed down by periods of self-doubt. All dentists understand the responsibility of becoming clinically and technically competent. However, to fully understand the significance of putting the patient’s interests above one’s own requires some amplification.
First, it is important to note that trusting a professional is not the same as trusting a friend. Friends earn trust through years of demonstrating their worthiness. However, in the traditional understanding of the professions, a professional is someone who is to be given instant trust. In effect, patients trust that society is working properly. Whether or not they know it, patients trust that the profession’s system of education, credentialing, and licensure has produced a competent practitioner. And even before that, patients also trust that the knowledge of the profession can help them.
Edmund Pellegrino, a physician-ethicist who has written extensively about the physician-patient relationship, explains it another way: “Trust in professional relationships is forced; it is trust generated by our need for help. When we need a doctor, lawyer, or minister, we have no choice but to trust someone, though we might prefer to trust none.”21
This is important because of the vulnerability of those who need professional services, which derives from several sources. In all professional relationships, there is a baseline inequality of knowledge and skills. The dentist, for example, understands the problem and how to deal with it, while the patient may have trouble defining what the problem is or fully evaluating any treatment that might be provided. Vulnerability may be increased if the patient has a troublesome problem, such as pain, bleeding, or the consequences of trauma. Finally, perhaps especially in dentistry, fear and anxiety may lead to added vulnerability.
In considering patient vulnerability, keep in mind that a professional, etymologically speaking, “professes” to do good for another. The word profess has such a strong connotation of declaration and avowal that it essentially represents a promise to help. One promises to act not only with competence, but also with concern for the patient. Thus, because of the inequality of the doctor-patient relationship, and especially because of the vulnerability of patients, it is essential never to abuse that relationship.22 In other words, patients trust that their vulnerability, in Pellegrino’s words, “will not be exploited for power, profit, prestige, or pleasure.”21
Having discussed the day-to-day commitments between professionals and their clients or patients, we now turn to the traditional ideals and orientation of professions and how they function. In doing so, we rely on Starr’s three characteristics of a profession: specialized knowledge, service orientation, and self-regulation.
A Base in Technical, Specialized Knowledge
There is widespread agreement that one of the main characteristics of professions is the requirement of extensive, specialized university preparation.4,20,23–25 Furthermore, the length and extent of the education adds to the dedication of professionals and increases the probability that they will practice it for the remainder of their working lives.25
For Eliot Freidson, a sociologist whose field is the professions, the “formal knowledge” generated by the educational process tends to separate professions from other occupations. He states that, “It has been shaped into systematic theories that explain facts and justify actions. It involves hypotheses, axioms, deductions, and models. . . . Members of professions are the ‘agents of formal knowledge.’”4
The nature of the “formal knowledge” also means that it represents exclusive expertise that is understood only by members of the select group who have mastered and practice it.26,27 As Freidson puts it, a profession “requires theoretical knowledge, skill, and judgment that ordinary people do not possess, may not wholly comprehend, and cannot readily evaluate.”26 Therefore, each profession provides a service that is essentially a monopoly in its area of expertise. Thus for competent service, the public, of necessity, must consult with members of professions—at least, that is the conventional view of the professions.25
The specialized nature of professional education has several relevant consequences according to the traditional understanding of the professions. One is that its complexity requires that professionals keep abreast of current developments through clinical and scientific journals and continuing education courses. Another is that few others besides professionals are in a position to teach it and to expand that knowledge through research. Similarly, in most disputes involving the validity of professional knowledge, who else but its membership can serve as arbiters?24
A Service Rather Than Profit Orientation, Enshrined in a Code of Ethics
In the traditional understanding of the professions there is substantial agreement that for an occupation to be considered a profession, the population at large must believe that its services have significant social value26,27 and, as Freidson26 puts it, are also “Good Work.” To be so judged, one or both of the following two conditions must be met. One condition is that the services rendered must have intrinsic value that the public ranks very highly. For example, in medicine and law the preservation of health and life and the protection of self and property against the adverse actions of others both certainly qualify.25