Society’s Increasing Concern
Ethical standards in modern society are in a time of rapid flux and show the contradictions that characteristically attend such changes. This period of ethical re-evaluation received an abrupt stimulus in the 1960s from the great upheavals over civil rights and the Vietnam War. Contrasted with this is the current widespread concern about the behavior of public persons. A president has been impeached. Congressional ethics committees have taken aggressive action against colleagues. Distrust between political parties is increasingly problematic. Business leaders have been put on trial for deception and dishonesty. Public trust in institutions of all sorts, including most professions, has diminished.1 Consumers are better informed and demand more and better services, including those related to health care. On the other hand, strains of contradictory value systems run throughout society. Large segments of society are becoming more materialistic, more self-serving, less reflective, and less concerned for the welfare of the community.2
Despite these views, there is a growing advocacy for limiting what has been almost a century-long endorsement of unchecked “progress.” Significant portions of the population now feel that the world ecology is at risk, that resources are finite and must be guarded, that technology has created important ethical issues not previously recognized, and that there is something seriously wrong with our health care system, both its cost and its benefits.2
Upheaval in Medicine
Thirty years ago, there was little formal intellectual work that considered ethical questions in the health care professions. What ethical discussion existed was more or less limited to questions about physicians’ practices and how they were interrelated: Should physicians extend professional courtesy? Should they conceal from a patient their disagreement with a colleague’s diagnosis?
During the three intervening decades, medicine’s increased preoccupation with ethics has been phenomenal. The output of ethics literature was minimal in 1970. By 1980 the number of MEDLINE ethics references cited was 313. The number grew to 780 by 1989 and has continued to grow even more rapidly since then. Ethics consultants in hospitals are now commonplace, and most larger hospitals have ethics committees that offer a formal review of problems with ethical overtones.3 In addition, newspapers regularly feature stories illustrating ethical issues involving difficult decisions to be made at the end or the beginning of life.
One of the most important reasons for the growth in concerns over ethics is rooted in the tremendous technological advances that, at great cost, offer prolonged or improved life quality. With high-tech enhancements come questions about who gets the care, who pays for it, and how those decisions are made. Especially important are concerns over genetic engineering, reproduction, and termination of care.4,5
The huge increase in the cost of care is also of special concern. In 1960 the dollars spent on medical care were 5.9% of the gross national product. By 1990 the amount had risen to 12.2%6 and by 2001 to 14.1%.7 Considering the extent of the increase, it is natural to expect citizens to be concerned about ethics. This is especially true when the impact of the dollars spent is questionable. For example, the United States spends two and a half times as much money per capita on health care as does Britain, but life expectancy and other health parameters are quite similar.8
Consider, too, that most medical care is now covered, at least in part, by some form of health insurance. Health insurance in itself generates its own ethical issues. Traditional third-party payment systems encourage overtreatment and overutilization. Health maintenance organizations (HMOs) encourage undertreatment and underutilization.8
Several other factors have contributed to the increased attention or concern about ethical issues. Ethicists have branched out beyond their traditional roles in philosophy departments to enter the health care arena. Undergraduate courses in bioethics and concerns for the ability of future physicians to deal with the increasing complex ethical issues in medicine have set up demands for ethics courses in medical schools that previously had none. Practicing physicians, because of their lack of training in ethics, are often poorly prepared to deal with the ethical issues encountered in daily practice.4
Physicians also have nagging concerns about the desirability of medicine as a profession. Increasing controls by the federal government and by the insurance industry have decreased the time that physicians have available for patient contact. Public trust in physicians is of concern. The nature of medical practice is changing in that more doctors are being employed by organizations. Although physicians continue to control policies in these organizations, they perceive the trend toward “captive” physicians as being undesirable.1 Finally, since 1983, physicians’ incomes, while still very high, have started to decline for the first time.8 These factors, coupled with the decline in the college-age population and the increased attractiveness of other scientific, professional, and business occupations, have led to a decrease in the number of applicants to medical school. All of these factors form a context for the ethical issues that must be faced in today’s society.
Dentistry as a Reflection of Medicine
The recent growth of ethics literature in dentistry has been significant but is nearly 15 years behind medicine in terms of its analysis of dental-related ethical problems. Additionally, although a few books on dental ethics are available, the literature is almost exclusively limited to journal articles, whereas hundreds of books have been written on themes of medical ethics. Until 1993, when the first comprehensive books on dental ethics were published, the only applicable book available was limited to issues of informed consent.9
Still, there is a rising interest in ethics in dental education. The American Dental Association’s (ADA’s) Commission on Dental Education has set standards for ethics education and has made it a requirement for accreditation. In addition, all dental hygiene schools10 now have courses in professional ethics. However, the ability of these courses to stimulate valid ethical reasoning may be of concern because few of the faculty have formal training in ethics.
In clinical dentistry, the interest in ethics is considerably different from that of medicine. For example, there is nothing comparable to the ethics consultants or ethics committees that are becoming routine in the hospital practice of medicine. The main consideration in dentistry has not been about specific clinical issues such as that of the termination of care. Rather, it has focused on the ethical standards of the profession in the sense of concerns for excellence in the quality of care and the need to maintain public trust. The leadership in this regard has come from the American College of Dentists. The growing number of ethics-oriented continuing education courses is a reflection of those concerns.
Some of the ethical issues in clinical dentistry derive from technological advances that have somewhat paralleled those in medicine, although with fewer dollars at stake and less involvement in life-sustaining issues. Nevertheless, costly innovations such as computer-generated restorative procedures (ie, CAD/CAM), along with the increasing use of implants and lasers, not only serve to improve the quality of care but also make care more inaccessible to less affluent people.
The increases in costs of care in dentistry have been substantially less than those in medicine, but they still present ethical concerns in terms of the resulting benefits. In medicine the huge increase in costs has not improved morbidity or mortality statistics. In dentistry there has been a steady decline in caries rates in children and young adults over the last 40 years and a decline in periodontal disease as well. However, these improvements appear to be related less to patient care provided by dentists than to water fluoridation and the increased use of improved oral home care products, especially fluoride dentifrices and therapeutic mouthrinses.
In another parallel with medicine, the growth of dental health insurance has been significant. However, it has not reached the high level of coverage experienced for medical insurance. Statistics from 2000 show that 85.4% of the population had some form of general health insurance, whereas only 57.4% had some form of dental insurance coverage.11 Nevertheless, the entrance of insurance into dental practice has fostered significant ethical concerns about overtreatment and undertreatment, just as it has in medicine.
Medicine is becoming more concerned over its public image and its desirability as a profession. Dentistry, always sensitive to issues of public opinion and professional status, has also experienced some recent decline in that regard. The 2001 Gallup Poll on honesty and ethics in American professions placed dentistry eighth from the top, below nurses, pharmacists, veterinarians, physicians, grade-school and high-school teachers, and clergy, and immediately below college teachers.12 While eighth is not bad, it is several steps down from the top two or three rankings, where dentistry stood for decades. In one of his monthly commentaries in the Journal of the American Dental Association, Gordon Christensen offered five reasons why the public’s attitude toward dentistry may be changing. They include: “having a commercial, self-promotional orientation; planning and carrying out excessive treatment; charging high fees without justification; providing service only when it is convenient; refusing to accept responsibility when treatment fails prematurely.”13 Incomes of dentists, having declined over most of the 1980s, are now increasing once again. And although there is concern within dentistry about the trend for dentists to be employed by organizations rather than to be self-employed, the view of dentistry by dentists is improving.
The Nature of Ethical Problems
What constitutes an ethical problem in contrast with a clinical, scientific, or legal problem? It might appear that some problems are purely clinical or scientific. However, such a view is illusory if by that we mean that clinical or scientific decisions can ever be made without some value judgment. Every clinical, scientific, or legal problem involves an evaluative component. Evaluations can often be identified when words of appraisal appear, such as good or bad, right or wrong, should, ought, or must. Sometimes the evaluative words are not as conspicuously evaluative, but they convey value judgments nonetheless. Claiming that an effect is a “benefit” or that a treatment is “indicated” conveys such a judgment, as does identifying an effect as a “harm” or a “side effect.”
Of course, not all evaluations are moral evaluations. Some value judgments are esthetic, cultural, or merely matters of personal taste. Certain evaluations, however, are indeed ethical. Most of us can rely on common sense to tell the difference between ethical and other kinds of evaluations. The formal criteria of ethical evaluations will be discussed in chapter 3. What is critical to know at this point is that all clinical or scientific decisions require evaluations. Decisions are easy when the difference between good and bad is clear-cut. In other situations, decisions are more difficult, and choices must be made between good and good or between two evils.
The use of local anesthetics for cavity preparation offers a good example of the role of values in decision making. Dentists are taught to use local anesthetics almost routinely in cavity preparations to maximize patient comfort. The use of local anesthetics may also reduce the stress felt by the dentist who then does not have to worry about hurting the patient. It can also result in better treatment because, for example, more thorough caries removal is possible under good local anesthesia. In general, dentists value these consequences of local anesthesia to the extent that they often use it routinely even though procedures may be possible without it. Sometimes dentists may value the benefits of local anesthesia so much that they may refuse to treat a patient who requests that no local anesthesia be given or may try to pressure a reluctant patient to accept it. The frequent use of local anesthesia is not a major value issue in dentistry, but it does show the value dentists place on their ability and desire to relieve pain. Patients may hold values that differ from the dentist’s and lead to rejecting local anesthesia. They may find the discomfort of the injection worse than that of the drilling or they may not want to experience the posttreatment feeling of anesthesia. There is nothing incorrect about these judgments; they are simply different from those that dentists often make. Failing to ask patients about their judgments may lead to treatment without adequate consent.
Evaluation may become an ethical issue when the dentist realizes that the evaluation involves a trade-off between the value of reducing pain and other values that the patient may affirm. For example, the patient may fear the side effects of the anesthetic, may object to its duration, or may simply have a psychological constitution that tolerates dental pain. It is clear that there is no definitively correct value judgment here. The value judgment of the dentist and the patient may conflict. The dentist who does what he or she thinks is best for the patient could end up violating the autonomy of the patient.
Ethical Versus Legal
People sometimes confuse ethical and legal problems. Both the ethical and the legal involve evaluations. Ethical evaluations, however, appeal to what is believed to be an ultimate standard of right and wrong. Legal evaluations appeal to the evaluations of a particular society. Moreover, they merely express the society’s minimal standards of behavior that can be enforced. Hence, it is possible that some behaviors could be legal, but still unethical. Alternatively, some behaviors that are illegal might nevertheless be ethical. This could occur if a society makes a value judgment that ultimately turns out to be wrong. Laws enforcing slavery are an extreme example where the legal and the ethical are not identical.
Changing attitudes within society about health care and the growing tendency toward initiating malpractice suits has stimulated attitudinal changes within the profession. Thus, instead of viewing the law as a guide for providing treatment that is in the interests of their patients, dentists often view the law as specifying the behavior necessary to avoid malpractice.14
As a result, differences between law and ethics must be noted as well as similarities. It may be legal for a general dentist to provide comprehensive orthodontic care without adequate training but unethical to do so. Conversely, a dentist may consider it ethically justifiable to correct a cross-bite for a patient on a state medical assistance program with a relatively expensive treatment not covered under the program and charge the program for a relatively less expensive but insurance-covered space maintainer. This action, however, is illegal because, in actuality, no space maintainer is required or placed.