5

CASE: THE CHEAPEST WILL HAVE TO DO

Ina Kirchland, a sixty-eight-year-old widow in good general health, is in severe pain. She is squeezed in at 9:40 a.m., before another patient’s 10:00 a.m. appointment. Although her teeth are generally in good shape, her upper-left first premolar has been a problem for some time. Dr. Luban and Mrs. Kirchland have discussed it being only a matter of time before it will need a root canal or removal and replacement. After a quick examination, Dr. Luban says that time has now come; the lingual cusp has fractured and exposed the pulp.

Mrs. Kirchland does not have much money and is without dental insurance. She lives on her deceased husband’s social security benefits, which she supplements to some extent by providing day care in her home several afternoons a week. Her resources for dental care, as for everything, are very limited. Her constant anxiety about how to make ends meet is voiced at the outset of every dental appointment.

Dr. Luban prefers for Mrs. Kirchland to choose a root canal, post, and crown because of the importance of filling the space if the tooth ever has to come out, which they have discussed previously. But the root canal, even without an immediate post and crown placement, will certainly cost more than a simple extraction. Mrs. Kirchland can still elect to have an extraction with one of several kinds of fixed prostheses, but any one of those, considering the condition of the abutment teeth, will be even more expensive than the root canal, post, and crown, and an implant will be more than that. So Dr. Luban judges that the alternatives to the root canal, post, and crown are not useful options. Another possibility would be an extraction with one of several kinds of removable partial prostheses; this would cost Mrs. Kirchland less than the root canal, post, and crown, but the removable prosthesis might need replacement later on in the event of accidental breakage, carious abutment teeth, and so on, although such events could affect the other options as well.

Before going into all this, Dr. Luban thought he ought to mention the option of an extraction with nothing to fill the space; some of his older patients viewed this as the obvious thing to do. But Mrs. Kirchland immediately cut him off, saying, “Heaven forbid, not after all these years.”

Now, if Dr. Luban simply presents Mrs. Kirchland with just the facts about only three of these options—root canal with post and crown, extraction with some kind of prosthesis, and simple extraction and no replacement—he is quite certain that she will simply choose the cheapest therapy, even if she has talked in the past about filling the space if the tooth were ever lost and even if she is made aware of the minor risks of shifting teeth and altered occlusal function. “I am getting old,” she has said many times, “the cheapest and simplest will have to last me.”

Endodontic therapy can also be tricky; unusual canal anatomy or an as-yet-undetected fractured root might later mean removal of the tooth anyway. Dr. Luban certainly has to mention these possibilities in some way, but too much talking about what could possibly happen may cause the simple extraction to now look better to Mrs. Kirchland.

On the other hand, he can definitely control how much to stress this aspect of root canal therapy in his explanation. In fact, he can probably make his explanation of the alternatives persuasive in any direction he chooses. Dr. Luban can probably lead Mrs. Kirchland to choose the root canal by strongly emphasizing the benefits of endodontic therapy, post, and crown followed by the risks of an extraction and no replacement and the inconvenience of caring for a prosthesis—and its possibly needing to be replaced later on. He has serious reservations about doing this, though, because under such circumstances Mrs. Kirchland’s choice might not be very autonomous.

He could refrain from returning to the option of a simple extraction. But wouldn’t that leave Mrs. Kirchland even less free to choose? Doing so will keep her from knowing about a possible treatment that is still within the range of clinically acceptable therapy, even though it is not the preferred treatment for her clinical situation.

Yet Dr. Luban is certain that the root canal with post and crown is really worth her money. He also has doubts that a choice of either cheaper therapy would be any more of a free choice on her part—given her view of her financial situation and her evident anxiety about it.

What should Dr. Luban do and why?

A PROFESSION’S CENTRAL PRACTICE VALUES

The practice of each profession—that is, the application of its expertise for the benefit of its clients—is necessarily focused only on certain aspects of the well-being of those clients. No professional group is expected by the larger community to be expert in their clients’ entire well-being. Consequently, no profession is committed to securing for its clients everything that is of value for them. Of course, the achievement of any values for a profession’s clients will depend on an understanding of the relation of these values to each client’s whole person. It is precisely in this way that the expressed concern of many professions about being attentive to the “whole” client can contain an important element of truth. But there is always necessarily a certain limited set of values that are the specific focus of each profession’s expertise, and it is therefore the principal job and obligation of that profession to secure these for its clients. In this book these values are called the Central Practice Values of a profession’s practice.

The aim of this chapter is to propose an answer to the obvious question: What are the Central Practice Values of dental practice and of the dental profession? What specific aspects of human well-being is each member of the dental profession tasked to secure—as much as is possible under the circumstances—for each of its patients? In addition, if there are a number of Central Practice Values, it is important to ask if these are of equal importance or if some of them take precedence over others when all of them cannot be achieved simultaneously. That is, do they form some sort of ranked hierarchy?

Before considering these questions, however, two other questions must be addressed. First, who determines a profession’s Central Practice Values? Second, how can we identify the values currently accepted as the Central Practice Values for a particular profession’s practice in a particular society? Clearly, it is not the individual practitioner who determines what values are Central Practice Values for the dental profession and dental practice in a given society. Of course, each individual dentist does make a personal choice to accept the obligations of professional practice as a dentist, and in this respect each dentist’s commitment to the Central Practice Values of dental practice is his or her own doing. But the contents of this commitment, as chapter 2 explained, are the product of an ongoing dialogue between the dental community and the community at large. So when a person chooses to become a dentist, he or she accepts and commits to the values identified in that ongoing dialogue—that is, the Central Practice Values of dentistry as a recognized profession in this society, not to some set of values of the individual practitioner’s own devising.

The person who becomes a dentist may even consider the values currently accepted as Central Practice Values for dental practice in a given society to be in need of revision or significant adjustment. Such a person may therefore choose to work, as a member of the dental community, to change or adjust the values that both the dental community and the community at large accept as central for dental practice. Some subtle ethical questions can arise for such a dentist about the extent to which a member of a profession may, and sometimes even ought to, engage in conscientious refusal to serve values that he or she judges incorrect for that profession’s practice. But the starting point of all such reflections and choices must be the fact that the content of professional norms for a given profession in a given society is first of all the product of an ongoing dialogue between that professional group and the larger community. It is not the product of unilateral choices on the part of an individual practitioner or even on the part of the professional group alone.

VALUES FOR PATIENTS FIRST OF ALL

The expression “dentistry’s Central Practice Values” may seem to refer most importantly to the dentist’s values. But the intention of this expression is that it refers first of all to values for dentists’ patients. That is, dentistry’s Central Practice Values, as this concept is being offered here, refers first of all to the kinds of benefits that patients receive from dentists engaged in the practice of their profession (and that can directly or indirectly impact persons in general that may not yet be, or may never be, patients of a particular dental practice). It was stressed above that every aspect of dental practice is value laden, and this is the case in part because everything a dentist does in relation to a patient should be directed first and foremost to the achievement of a certain set of values for the patient. These values are called “central” to the practice of dentistry because it is they that should principally shape every aspect of a dentist’s professional practice. They are called “practice values” because what they should shape is whatever the dentist does in caring for the patient; they are the values that the dentist is striving to bring about for the patient and that the dental profession is striving to bring about for the whole society.

Of course, it would not only be very strange but probably psychologically impossible for someone to become a dentist who does not personally value the kind of benefits that dental expertise enables a dentist to bring about for his or her patients. So we can expect dentistry’s Central Practice Values to be aspects of human life that a dentist personally values as well. But throughout this chapter and in their use as guidelines for ethical dental practice, it should be remembered that the first reason the Central Practice Values of dentistry should be pursued is because they are precisely the values that dentistry has committed to the larger society to strive to bring about for those they serve—that is, first and foremost, dentistry’s patients.

IDENTIFYING A PROFESSION’S CENTRAL
PRACTICE VALUES

How, then, can we identify the values that are currently accepted as central for the dental profession and dental practice in our society? The short answer is that we must carefully examine the conduct and the discourse of the members of the society and the members of the profession, as well as their interactions with one another. That is, we can identify the Central Practice Values by carefully examining the conduct and discourse of members of the dental profession and their patients as these parties discuss and then make decisions about dental treatment. These values can be identified, in part, by examining the kinds of reasons that dentists and those they serve offer for their recommendations, choices, and actions and the reasons that they accept from one another as reasonable, along with the kinds of reasons that are given and accepted in the society at large for justifying dentists’ and patients’ decisions in practice and in their relationships with each other.

In spite of its length, this is the “short” answer because the long answer involves the actual work of sifting through and sorting out all the data about conduct and discourse that pertains to the practice of dentistry in the society. In fact, without noticing it, all of us who deal with the dental profession in our society, and certainly both the established and the aspiring members of the dental profession itself, constantly absorb and contemplate this data to form an understanding of what is taken for granted about the Central Practice Values of dental practice in our society.

Ideally, those who are most concerned about the dental profession and dental practice perform this work of sifting and sorting much more explicitly and self-consciously. They then try to articulate what they observe in accepted patterns of conduct and discourse so that other concerned parties can evaluate their proposals and offer the evidence of their own observations and experiences until a genuine consensus about the contents of accepted professional norms can be formed. The accounts of the accepted norms of dental practice that appear in the codes of ethics of professional organizations and the sets of advisory opinions about such codes are examples of such efforts. The historical strength of each organization’s contributions to these deliberations, of course, varies. The account of the accepted norms of dental practice offered in this book (and the discussions in articles and books by other scholars of dental professional ethics) is thus another part of this process.

The codes of ethics proposed by organized dentistry have a special importance in this effort because they are commissioned and supported by large and longstanding historical groups of dentists. Thus, their authors have far more claim to be representative of the dental community than the three authors of this book have or the authors of other scholarly articles and books have. At the same time, the details of their deliberations in determining the content of such codes are rarely made known to the larger society, and it is extremely rare that members of the nondental community are represented at all in the creation of such codes. Consequently, the codes are often representative of only one side of the dialogue. On the other hand, a book like this or a scholarly article on a particular topic in dental professional ethics can examine the accepted norms of dental practice, raise questions about the reasons supporting them, and propose possible alternatives to them and other considerations—in far more detail than any published code or set of advisory opinions can do. Thus, both efforts are needed to help make the contents of the ongoing dialogue more articulate.

From what has been said, it follows that the many statements about professional norms and obligations made in this book should be read as hypotheses about the contents of the current dialogue between the dental community and the community at large. These statements aim to focus on and help clarify the norms and values that the two groups accept as shaping the dental profession and dental practice in our society. Yet, while these are “only” hypotheses, the accounts of professional norms and obligations offered here are not mere constructions of the authors’ imaginations. They are based on extensive and careful analysis of our society and its dental community using the most sophisticated concepts about the nature, basis, and implications of professional obligation available, many of which are also summarized in this book so that they, too, can be thoughtfully evaluated by the reader.

The authors believe that the claims made in these pages about the contents of dentistry’s professional norms are in fact well supported by the data; that is, they are supported in the conduct and discourse—in the actions undertaken and in the reasons given—of dental professionals, their patients, and other members of the larger community.

DENTISTRY’S CENTRAL PRACTICE VALUES

As dentists care for patients, they make numerous decisions that are inherently value laden. Most of these do not involve conscious examination of competing values by the dentist, because the values the dentist is guided by are the fruit of well-established habits of professional practice. But whether the value content of a particular judgment is explicit or implicit, a dentist cannot practice without making numerous decisions in which values play an important role. The practice of dentistry, in other words, is not only a matter of technical judgment and skill; it is also an activity in which the dentist strives to bring about certain values, either directly for the patient or as part of his or her relationship with the patient.

To make the same point in another way, consider a dentist who focuses his or her efforts principally on entertaining the patient and receiving the patient’s plaudits as a result, even if this means forgoing procedures needed for the patient’s oral health. Or consider a dentist who works chiefly to give patients the excitement and exhilaration that some people experience when facing a serious risk head-on, so the dentist therefore makes little or no effort to control or minimize the risk to the patient in advance. Such dentists would have a limited clientele, of course. The risk-adverse would not be interested in the latter dentist, and patients who go to dentists for more familiar reasons would probably avoid both of them. But many people enjoy being entertained, and there seem to be people who enjoy risk-taking enough that each kind of dentist might still have regular patients. Would either of these practitioners be practicing in a professionally acceptable way, even if they had patients? The answer to this question is clear. Neither of these ways of employing dental expertise is professionally appropriate under the accepted standards of dental practice in our society. Regardless of whether a person could actually earn a living doing such things, these ways of acting are not proper ways for a person who claims to be a dentist to act. They are misdirected; in fact, precisely what is wrong with them is that they are directed at the wrong values.

As in every profession, there are certain values that are central to the proper practice of professional dentistry, and every dentist is committed, as a professional, to working to achieve these values above all for his or her patients. What are dentistry’s Central Practice Values? There are six values that appear to be the accepted Central Practice Values for dental practice in our society:

1. The Patient’s Life and General Health
2. The Patient’s Oral Health
3. The Patient’s Autonomy
4. The Dentist’s Preferred Patterns of Practice
5. Aesthetic Values
6. Efficiency in the Use of Professional Resources

The question of whether these six values are hierarchically ranked will be discussed later in this chapter. But before that, each of the six must be explained in its own right.

The Patient’s Life and General Health

One value that certainly plays an important role in dentists’ judgments in practice is the value of the patient’s Life and General Health. Although this value is not discussed as much as that of the patient’s Oral Health, nevertheless every patient that a dentist examines and every treatment that a dentist recommends or performs must be evaluated on the basis of this value. A dentist who recommends a treatment or ignores or denies a condition that places a patient’s life at risk without any consideration for this fact would certainly be acting unprofessionally. Moreover, a dentist who pays no attention to the connections between a patient’s oral condition and other aspects of the patient’s health would be similarly guilty of a serious professional failure.

It will be important to reflect on the relative importance of this value—the patient’s Life and General Health—in comparison with other values in dental practice. Is it correct to say that the patient’s Life and General Health should take priority over all other values that a dentist strives to achieve, or are other values more important than this in the practice of dentistry? This question will be examined in detail in the next section. But first, a description is needed of the other five Central Practice Values for dental practice.

The Patient’s Oral Health

The patient’s Oral Health is the most obvious value that dentists aim to achieve for their patients. Although it may appear to be a fairly simple idea, oral health is actually quite a complex notion. There are general standards of appropriate oral function, of course, but the specific character of appropriate functioning for a particular patient will depend on many variables, including the patient’s age, the pattern of development of the patient’s dentition, other health conditions, the patient’s physiological and functional needs, the patient’s underlying anatomy, and so on. Oral health also includes the notion that oral functioning is pain free. But pain and discomfort are also relative terms, and the specific standard that a dentist should apply to a given patient will also depend, at least in part, on variables like those already mentioned. Nevertheless, in spite of the complexity of its content, oral health plays a very important role in the judgments dentists make every day in practice. For present purposes, the Central Practice Value of “Oral Health” will be defined as appropriate and pain-free oral functioning.

The complexity of the notion of oral health is in fact just an extension of the complexity of the idea of health itself. Health is not merely a factual concept. It is an evaluative concept as well because it is used to identify certain characteristics and conditions as being preferable for humans, as the ones humans are better off having. It is beyond the scope of this book to study the larger concept of health in any detail, but all who are health care providers, including members of the dental profession, would do well to think carefully about the meaning of this concept and its implications for their professional practice.

The Patient’s Autonomy

“Autonomy” was discussed at some length in the preceding chapter. The brief definition adopted there, “choosing and acting on the basis of one’s own values, goals, purposes, and principles of conduct,” will continue to be operative in this discussion of Autonomy as one of dentistry’s Central Practice Values.

The prominence of the professional-legal principle of Informed Consent and the reasons given in chapter 4 for considering the Interactive Model to be the ideal model for the dentist-patient relationship should be reasons enough for this list of dentistry’s Central Practice Values to include the patient’s Autonomy. However, later in this chapter, when the relative importance of dentistry’s Central Practice Values becomes the focus of discussion and they are ranked, the question of the relative priority of the patient’s Autonomy will be shown to be more complex.

The Dentist’s Preferred Patterns of Practice

The dentist who practices in a technically competent manner still has many choices to make. Among these choices are some that might be noticed by a thoughtful layperson. For example, the dentist must choose among various kinds of dental chairs and various ways of laying out an operatory. But dentists make many more choices that laypeople are rarely aware of, and many of these choices are much more important. There are, for example, choices among various styles and brands of hand instruments, various kinds and brands of medicaments, various dental materials, and so on. There is a wide range of choices to be made regarding the worth and maintenance costs of major dental equipment because the available technology changes and advances so rapidly. Still more complex than these are the dentist’s choices among various acceptable approaches to most of the diagnostic, operative, and other procedures in dental practice. A dentist must make choices in all these areas, weighing the options in terms of patient outcome and patient comfort, of course, and also in terms of the dentist’s own output of time, effort, and money, and the dentist’s degree of comfort with and trust in each alternative as well as the dentist’s ability—determined in practice through repeated use of the procedure or technique—to become able to habituate its use rather than continuing to have to focus on every step or detail of its use, as at the start.

It might seem that no special values are involved in these choices other than those mentioned under the other headings in this section—that is, dentistry’s other Central Practice Values. It might seem, in other words, that once those other values have been fulfilled, nothing else is at stake but the dentist’s own preferences, which will vary from dentist to dentist. But in fact, there is a subtle professional value at stake in these choices that needs careful articulation because it is so easily overlooked.

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