Ethical Decision-Making and Conflicting Obligations
When Dr. Sharon Sullivan returns from lunch around one o’clock, she notices a new patient in Operatory 2. “Who’s in Op. 2?” she asks her hygienist, Elizabeth Minowski. “The day list says she’s Edith Blake, but I don’t recognize her.”
“She’s an emergency,” Elizabeth explains, “says she’s been in pain for three or four days, but it’s obvious she hasn’t seen a dentist in a long time. Every quadrant has caries and perio involvement. She lives at the Transition Home. Someone there sent her over.”
“Where’s the pain?” asks Dr. Sullivan.
“Upper left. I saw a large lesion in #13, but the gums are also swollen and red. She was squeezed in as an emergency patient before Mrs. Livingston at 1:15. I just glanced over her history form, introduced myself, and got her in the chair. I had a quick look when she was pointing out her problem, then I heard you come in. Do you want me to take radiographs and do the charting before you look at her?” asks the hygienist.
“No, Liz,” says Dr. Sullivan. “Mrs. Livingston isn’t here yet, so I might as well see her myself. But what do you mean they sent her over from the Transition Home? What’s that?”
“The Salvation Army runs a home over on Third Street for women trying to get out of prostitution. I thought you knew about it. Carolyn Elward was a patient of ours before Dr. Bingley retired, and she used to be one of the supervisors there. Anyway, Ms. Blake is a resident at the Transition Home. She says her hall leader told her she should see a dentist when aspirin wasn’t controlling her pain. She was sent here because she could walk here from there.”
“Okay. When Mrs. Livingston gets here, have Jane explain to her that she may have a little wait because of a patient with an emergency,” says Dr. Sullivan. “She’s better in the waiting room than in a chair because she gets so anxious once she’s back here in the operatory.”
“Hello, I’m Dr. Sharon Sullivan,” Dr. Sullivan says to Ms. Blake. “Ms. Minowski says you’ve been having quite a bit of pain in the top-left part of your mouth. What do you want us to do?”
“Yes, it’s been hurting for three or four days, but this morning it got so bad that even aspirin wouldn’t help it.”
“Do you mind if we chat while I take a look around your mouth?”
“Oh no, go ahead, I already like you guys and I love to talk.”
“How long is it since you’ve seen a dentist?”
“It’s been a long time,” says Ms. Blake. “Since I was in high school.”
“How old are you now?” asks Dr. Sullivan.
“I’m twenty-six, so almost ten years, I guess.”
“Well, I’m sorry to say, your teeth do have some problems.”
“I’m not surprised,” says Ms. Blake. “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. Actually, I didn’t care much at all what happened to me then, to be honest.”
“I think I understand,” answers Dr. Sullivan. “Ms. Minowski mentioned that you’re staying at the Transition Home now. Is that helping you get a better hold of things?”
“Oh, yes,” says Ms. Blake. “I feel safe there. I’m even starting to think it’s worth it to take care of myself. The counseling, the other girls who live there, and the girls who finished the program and come back to talk with us all help a lot. They really know what it’s like to be on the street and what it does to you and how you think about yourself. The Little Handbook they give out says the first goal for every girl is to restore her 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 phone. But it’s not easy to get off the street. You can’t just walk away. But something told me I had to try it, and I went there five weeks ago and they accepted me into their program.”
Meanwhile, Dr. Sullivan completes her examination. Besides the deep cavity in the upper-left second bicuspid that is very tender to touch and the likely cause of Ms. Blake’s pain, there are other carious lesions in half a dozen other teeth and generalized periodontal involvement with deep pockets in several sites as well, plus several other areas that need a closer look once all the X-rays are taken. At first glance, though, it seems that all of the teeth are probably salvageable, but Ms. Blake clearly needs a lot of dental work. Dr. Sullivan excuses herself to see if Mrs. Livingston has arrived and to ask Ms. Minowski to take the needed X-rays.
“Excuse me for asking, Dr. Sullivan,” says Ms. Minowski, “but have you talked to her about paying for this?”
“Actually, no, Liz,” says Dr. Sullivan. “I was focused on getting the exam done before Mrs. Livingston got here, so I haven’t even considered money yet. Since she is already in the chair, let’s see what it will take to get her out of pain and then we can figure out the money part.”
“That’s why I mentioned she was from the Transition Home. I doubt she has money to pay for a lot of dental care,” says the hygienist, “and she doesn’t have a medical card or any insurance.”
“And you were trying to clue me in by mentioning the Home?”
“Well, I appreciate the effort, but I didn’t get the hint,” says Dr. Sullivan. “Let’s do the X-rays first so we know what we are talking about and I will get started with Mrs. Livingston.”
Mrs. Livingston’s checkup goes quickly, and Dr. Sullivan returns to the operatory to talk with Ms. Blake about what she has found during her examination. “I haven’t had time to look at your X-rays to make sure there aren’t any other problems that I can’t see, but even if there aren’t, it would take at least three or four visits to do a proper cleaning of all your teeth and then deal with the other large cavities that I can see just by looking. Then we would have to decide how much additional treatment you will probably need for the gum problems.”
“I don’t have that kind of money,” says Ms. Blake. “I told the woman at the front desk that I didn’t know if I could pay for this, but she said you wouldn’t send me away in pain. Then you were so nice and talking with me that I forgot to say anything. I’m sorry.”
“Well, I enjoy talking with you, too,” says Dr. Sullivan, “and that’s probably why I forgot to mention it myself. But you really do need to get your teeth fixed or you will have more bouts of pain and maybe something worse. We could arrange a long-term payment plan so you wouldn’t have to pay a lot of money right away. We do that with many of our patients.”
“The work I do at the Home helps pay my room and board. I only get $30 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 then they come back for counseling and to help the girls who are still there. But I won’t be able to do that for at least two more months or maybe more.”
“I don’t want to take your $30, Ms. Blake,” Dr. Sullivan says. “If you can stay for a while this afternoon, I will work around the other patients in my schedule and take care of the big cavity in your upper-second bicuspid because that’s probably what’s causing your pain. I won’t need to charge you for that if you can stay here and I can fit it in between my other patients.”
“That’s 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,” says Ms. Blake.
“My real concerns,” says Dr. Sullivan, “are your other teeth. You will be in here again in no time if they aren’t attended to, and your teeth need a good cleaning so you can start taking proper care of them again. They’re worth it and so are you.”
“Well, I will start brushing them like I am supposed to, but they hurt and bleed when I do. Anyway, 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,” says Dr. Sullivan. “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. Do you mind hanging around? In the meantime, I will ask Ms. Minowski to do a basic cleaning, just to get you started.”
“Will you at least take my $30?” asks Ms. Blake. “I’m sure it’s nowhere near enough, but I want to be fair to you, and you have already been too kind to me.”
“Let me think about that,” says Dr. Sullivan. “I’ll be back in a little while. I’ll get Ms. Minowski in here shortly.”
Dr. Sullivan actually has a lot to think about. First, there is the financial question, not just about the $30 but also about Ms. Blake’s need for considerable dental work. For now, let’s set aside the possibility of Medicaid benefits, which vary from state to state and from one time to another. One obvious possibility would be for Dr. Sullivan to accept a major financial loss and address all of this patient’s dental needs in the best way possible for no payment or a little symbolic payment for each visit. Or she could find a way to help her some but not provide the best possible care—for example, by using composite buildups instead of crowns so that it would be less of a loss for her. Or maybe she should let Ms. Blake postpone the rest of the care she needs until she has a job and then work out a payment plan for at least some of it while taking the rest as a loss. Or she could just tell Ms. Blake what she needs and leave the decision up to her, regardless of whether the patient can afford it or not.
Besides that, Dr. Sullivan has seen some marks on Ms. Blake’s arms that suggest she might have been an IV-drug user at some time, probably during her days on the streets, and bruises that might indicate previous instances of abuse. Dr. Sullivan wasn’t comfortable raising these questions with Ms. Blake in this first visit. But a dentist’s observations can raise potential questions about other risks to the patient that may or may not be appropriate to raise once a more lasting relationship between patient and dentist has been established. The possibility of Ms. Blake having become HIV positive also raises a question about whether this could involve risks for Dr. Sullivan and her staff if they were to treat her.
All in all, Dr. Sullivan has a lot of thinking to do. What level of charity care is she professionally obligated to provide for Ms. Blake? Are there limits to her professional obligations in a case like this? Are there things she could do that would be above and beyond the call of her professional obligations, and should she do them even though it is beyond what is required of her? And, for each of these options, are there other factors besides being an ethical professional that should impact how she weighs the pros and cons?
Many professional-ethical judgments are easy and straightforward and, like most actions in other areas of our lives, they are mostly the result of good habits; rarely do they need to be carefully thought out and self-consciously chosen each time they arise. Of course, thoughtful people carefully examine their professional habits from time to time, as well as their other moral habits. As chapter 1 indicated, it is precisely reflection of this sort that legitimates the claim that actions done from habit are still rationally chosen actions, even though they are not the product of explicit deliberation in the situation. The examples used in this book, however, all focus on what a dental professional, thinking carefully about a particular case, might consider when determining how to act in the case. But this book also hopes to stimulate careful reflection on the reader’s habits of professional conduct and ethical reflection. It is always good to ask, after thinking carefully about a particular case, whether what was learned in the case tells us anything valuable about habits that we have (or don’t have) that impact our professional-ethical lives.
For all the centrality of habits in our moral and professional lives, though, there are three kinds of circumstances that can arise where determining what one professionally ought to do definitely requires explicit and careful deliberation on the alternatives at hand; these are (1) when a situation requires a professional to think about the limits of his or her professional obligations and, then, the extent to which he or she is committed to sacrificing other things for the sake of a patient, (2) when one’s professional obligations are themselves in conflict, and (3) when a person’s professional obligations conflict with other commitments or his or her obligations to other people.
The most difficult ethical dilemmas professionals ordinarily face involve one or more of these circumstances. Yet none of them has been discussed very carefully in the dental ethics literature or the literature on professional ethics generally. Discussing them here will not yield some tidy algorithm that readers can apply to resolve difficult ethical questions. This chapter aims, instead, to shed useful light on dentists’ most difficult ethical decisions by first reflecting on the general structure of ethical thinking and then on the characteristics of each of these three sets of circumstances.
When a dentist is faced with making an ethical decision in an unusual or ethically complicated situation, it can help a lot if the dentist has already reflected on the components of a carefully thought-out ethical decision. What will be proposed here, then, is a model of the steps of professional-ethical decision-making. Any model of decision-making is necessarily an oversimplification because it focuses on specific aspects of ethical thinking and treats them as separate “steps” of the decision-making process. In actual ethical reflection, these “steps” are highly interdependent and we do not completely finish Step Two, for example, before beginning Step Three. Instead, we move back and forth between the different steps, learning from one of them that we haven’t adequately answered another and gathering data from one of them that proves informative for another, and so on. It is still worthwhile, though, to carefully separate and describe the several distinct kinds of thinking involved in ethical decision-making. This is because, when an ethical decision is particularly complex, having a kind of “road map” of the steps involved can often be very useful.
Step Zero: Getting the Facts
This model presumes that the person using it has already carefully identified all the relevant facts—that is, about the situation, the people involved, the possible actions that might be chosen, the probability and possible outcomes of these actions, and so forth. It would obviously be a mistake to learn the steps of this model and then use it without always stopping to ask, “Do I have all the facts I need, and have I understood them all correctly?” As with the other steps in this model, however, there is no assumption here that we always finish Step Zero completely and only then begin the rest of the process. Often our need to address the issues in a later step in the process requires us to “go back” and get some more facts or to check our facts again. This is because of factors we did not notice at first. This model will not, however, attempt to describe the methods that careful thinkers use to “get the facts” they need. Therefore, “Getting the Facts” will be considered “Step Zero” in this model of Professional-Ethical Decision-Making.
Step One: Identifying the Alternatives
Step One consists of determining what courses of action are available to choose between and then identifying their most important aspects. Sometimes options are obvious from the facts of the situation and do not require one to stop and think carefully about it. But at other times it can be difficult to see what the alternatives are. Certain circumstances about the situation, or our own habitual ways of perceiving and acting, can cloud our vision of what actions would be possible for us. So it is always useful to make a point of explicitly asking what courses of action are available to us and what would be the likely outcomes of each of these alternatives. In addition, we will often need to ask about each of our alternatives, what other choices, for ourselves and for others, are they likely to lead to. It is also important to ask, in most situations, how likely it is that the various possible outcomes and future choices that we can envision will actually occur.
Dentists are typically well trained to identify the clinical alternatives for a given patient’s presenting condition. Professional-ethical decision-making requires that dentists also carefully identify the alternative ways in which the dentist might act in relating to the patient or other persons involved and in responding to other nonclinical aspects of the situation.
Step Two: Determining What Is Professionally Important
Once the alternative ways in which a dentist might respond to a situation have been carefully identified, the dentist needs to examine them from the point of view of what ought and ought not be done professionally. Each of the identified alternatives must be examined from this point of view. The criteria to be used in this step of the decision-making process are the ethical standards of one’s profession (i.e., the content associated with each of the nine categories of professional obligation that were identified in chapter 3). The principal purpose of this book is to help readers come to a more detailed and more sophisticated understanding of dentistry’s ethical standards so that determining what is professionally important about each of the alternatives and their likely outcomes can then be done with greater precision and professional confidence.
Step Three: Determining What Else Is Ethically Important
Each alternative must be examined specifically from the point of view of the broader criteria of what ethically ought and ought not be done. This step goes over and above the specific ethical standards of the person’s professional life, for one’s professional obligations never constitute the entire moral content of a person’s life. Moreover, the professional standards themselves have become dentistry’s professional standards for certain reasons; that is, they have been accepted by the profession and the larger community in dialogue as dentistry’s ethical standards so that the dental profession and its members will serve their patients and the larger community well. Therefore, if in a given situation specific professional-ethical standards conflict with one another, or if they fail to adequately direct which possible action would be professionally and ethically best in the situation, then the reasons behind the specific ethical standards should be considered—that is, the thinking that goes into determining what constitutes dentistry’s serving its patients and the larger community well. Situations will also arise when a dentist’s other commitments conflict with his or her professional commitments; in these situations, even more fundamental moral categories will need to be considered.
The details of the thought process in such situations will depend on the particular approach that a person takes to ethical reflection in its “largest” or “deepest” sense. Ordinarily, at the most general level, people do their moral reflection chiefly in terms of maximizing certain values for certain people or possibly for everyone affected, conforming to certain fundamental moral rules, respecting certain fundamental rights, or actualizing certain human virtues. So the details of this process will ordinarily have one or the other of these structures, or it may combine several of them together.
Many professional-ethical decisions will not require the kind of ethical thinking described here as Step Three. This is because the decision can be properly made solely on the basis of the ethical standards of the dental profession. The careful professional-ethical thinker will make a point, though, of at least asking whether anything about the situation is ethically important in some other way or for some other reason.
Step Four: Determining What Ought to Be Done (Ranking the Alternatives)
The process of determining what is professionally important and, if needed, what is ethically important for other reasons will sometimes lead, without further effort, to the conclusion that one of the alternative courses of action is what ought to be done. At other times, matters will be more complex because the relevant professional standards, on the one hand, and other ethically important values, rules, rights, virtues, or other kinds of ethical reasons that you judge to be relevant, on the other hand, favor different courses of action. Then one’s determination about what ought to be done becomes a careful judgment about which of these competing sets of ethical norms is more suited to be the determining factor in one’s decision about the situation.
Trying to determine what ought to be done sometimes leaves a person with a choice between several equally superior alternatives. For example, one’s leading alternatives can be functionally equal because of the person’s inability or lack of time to get all the information needed to judge more carefully between them. Or the leading alternatives may be equal precisely in that, with regard to competing professional and ethical standards, neither is more suited than the other to be the determining factor in one’s decision. In such cases of equally superior alternatives, one may morally choose either of them because they are equal in professional or ethical merit and they are superior to every other alternative considered.
When a person does carefully judge that several alternatives—that are ethically superior to all the others—are either equally suited to the situation or functionally equal because of lack of time or information, then the person must resolve the situation by choosing between them; the faculty of judgment will then have done the best it can under the circumstances. It is a presupposition of this model of professional-ethical decision-making that choosing to act in a certain way is a specific kind of activity that is distinct from the activity of professionally or ethically judging about possible ways of acting.
Most sociologists who have studied the institution of profession mention “commitment to service” as one of the essential features of professions. Similarly, most health professions describe themselves, in their codes of ethics and elsewhere, as giving priority to patients’ interests or being in the service primarily of the patient. To cite one example, the preamble to the American Dental Association’s (ADA’s) Principles of Ethics and Code of Professional Conduct (hereafter ADA Code) begins: “The American Dental Association calls upon dentists to follow high ethical standards which have the benefit of the patient as their primary goal.”
But expressions like “service to the public” and “benefit of the patient” as one’s “primary goal” admit of many different interpretations with significantly different implications for actual practice. Four different interpretations of such expressions will be examined in this section in order to provide a framework for discussing the extent of dentists’ professional-ethical obligations and the amount of sacrifice of other interests that a dental professional ought to undertake.
A Minimalist Interpretation
The dentist’s commitment to serve could mean only that dental professionals have an obligation to consider the well-being of their patients when deciding how to act in particular situations and when forming the habits that shape their daily work with patients. This statement has to be considered a Minimalist Interpretation of the professional commitment to serve because the patient’s well-being would not have any special importance in the dentist’s professional life if the dentist gave the patient any less consideration than this. But obviously, in this interpretation, the well-being of dentistry’s patients would not be given priority over any other of the dentist’s concerns. In fact, in this Minimalist Interpretation, only two situations would clearly violate a commitment to the priority of the patient’s well-being. First, a dentist’s failure to consider the patient’s well-being when the patient’s well-being would certainly be affected by that dentist’s choice, and, second, a dentist knowingly choosing an action that was detrimental to the well-being of the patient and doing so for the sake of something the dentist truly thought was not very important at all. However, given how health professionals in general, and dentists in particular, view themselves, and given what the larger community routinely believes and expects about health professionals’ obligations, it is clear in our society that dentists are regularly understood to be committed to giving some kind of priority to the patient’s well-being in the decisions they make. Therefore, the Minimalist Interpretation is clearly an incorrect understanding of dentists’ professional obligations. The same conclusion is supported by sociologists’ research into the health professions. We must, therefore, set aside the Minimalist Interpretation and consider others more carefully.
The Maximalist Interpretation
At the opposite extreme is the Maximalist Interpretation. This is what the common expression “putting patients first” (stated in just this way, i.e., without any qualification) seems to be saying about dentist’s professional obligations. In this interpretation, the commitment to the priority of the patients’ well-being would mean that dental professionals are obligated to place the well-being of their patients ahead of every other consideration—that is, not only ahead of all their own other interests and concerns but also ahead of every other concern and obligation they might have regarding any other person or group. This is a very extreme view of the professional’s obligation to serve others. It deserves examination here because the rhetoric of the professions—especially the phrase “putting patients first”—so often seems to be giving the public and dentists just this message.
This Maximalist Interpretation, however, cannot reasonably be the correct view of the dentists’ professional obligations to their patients. There would be very few health professionals if the Maximalist Interpretation were to be taken as accurate, and people would obviously suffer greatly if this was the case. Moreover, few health professionals, and very few members of the larger community, actually believe that dentists—or any other health professionals—really are obligated to place their patients’ well-being ahead of literally everything else in their lives. So the question about how much priority dentists owe to patients’ well-being needs to be carefully examined, precisely because we know the correct answer cannot be that dentists are obligated to make everything—absolutely everything—subordinate to the well-being of their patients. This Maximalist Interpretation must also be set aside. We must now examine interpretations of the priority of the patient’s well-being that fall between these two extremes.
The Parity Interpretation
One intermediate interpretation can be called the Parity Interpretation, where the word “parity” refers to the equal importance of the patient’s well-being and the dentist’s other valued concerns. In this interpretation, the dentist is professionally obligated to hold the patient’s well-being to be at least equal in importance to his or her own well-being and any other important concerns or responsibilities the dentist might have. The dentist would thus be obligated to choose the patient’s well-being over any aspect of his or her own well-being or other concerns that the dentist judged to be of lesser significance than the effects of the dentist’s actions on the patient’s well-being.
With this interpretation, it is important to note, the dental professional is ethically permitted to choose his or her own well-being or other valued concerns over that of the patient in any situation in which the aspects of well-being at stake for the patient and dentist are of equal importance. That is, if the effects of the dentist’s action are equal in their impact on the patient and on whatever the dentist holds highly valuable, then, in the Parity Interpretation, the dentist is not professionally obligated to accord greater significance to the patient’s well-being than to his or her own important concerns. In such a case the dentist would be choosing between ethically equal alternatives and may therefore ethically choose either one.