The standard ethical arguments that prescribe dentistry’s involvement in improving access to oral health care are based on the ethical principle of social justice. The authors underwrite this principle but argue that, as with other ethical principles, this principle alone will fail to have a practical impact. The authors show that the issue of access is a symptom of a more systemic problem in dentistry, namely the lack of connectedness that dentists feel between themselves and their profession, their community, and society at large. The second half of the article develops a plan for boosting “connectedness.” Successful implementation should help resolve many of the systemic problems that dentistry currently faces, including the issue of disparities in oral health.
The standard ethical arguments that prescribe dentistry’s involvement in improving access to oral health care are based on two related ideas. The first is that the ethics of social justice compels dentistry to make the distribution of its services more equitable, with special attention to the most vulnerable in the population. The other is that, because disparities in oral health are, by their nature, unfair, then dentistry, with its eminently strategic position in oral health care, is obligated to do something about the disparities.
The authors agree with these positions, but they also acknowledge that there is a wide gap between the theoretical ideals of justice and their application to actual practice. Overcoming this gap often is difficult. An egalitarian’s delight may be a libertarian’s nightmare. When it comes to getting things done, the principle of justice often invites a stalemate, not a solution.
In this article the authors present the view that ethical principles will fail to have an impact unless they are supported by a robust sense of professionalism. This theme is elaborated in the context of two broad goals. The authors first show that the issue of access is a symptom of a broader problem in dentistry, namely the lack of connectedness that dentists feel between themselves and their profession, their community, and society at large. They argue that this pattern of disconnectedness (or isolation) also contributes to other urgent challenges to the profession. The authors then show how the introduction of “connectedness” can facilitate the resolution of these problems. The authors believe that their proposal to “get connected” actually harkens back to the very roots of the dental profession, to the early 1830s at a time of crisis both for the country and its early dental practitioners, when visionary dental leaders managed to establish the foundation of public trust on which the fledgling profession was accepted and grew. The authors argue that a more robust connectedness between dentists, their patients, their profession, their community, and society at large will facilitate the resolution of many of the systemic problems that dentistry currently faces, including the issue of access to care.
Access to care as a symptom of dentistry’s disconnectedness
The United States Surgeon General’s report, Oral Health Care in America , brought to public attention the extent and seriousness of oral disease in this country’s most vulnerable people, that is, “poor children, the elderly, and many members of racial and ethnic minority groups.” Disparities in oral health have many different causes, some of which are far beyond the scope of the profession, as is true of most of the systemic challenges faced by dentistry today, and indeed by all professions. Individual dentists and the dental profession at large are also part of the problem, however, and do share in the responsibility for correcting it.
The authors submit that the root cause for dentistry’s relative ineffectiveness in reducing disparities in oral health (relative, that is, to other health professions) lies in its longstanding pattern of disconnectedness, or isolationism. As the American Dental Education Association (ADEA) has pointed out: “Reduced access to oral health care is one of the prices of professional isolation that has too often characterized dentistry.”
The tendency of dentists to focus on their own privacy negatively affects their inclinations and attempts to deal with broader issues, including the staggering disparities in oral health. Many dentists consequently point outside dentistry—to state and local government, to insurance companies, to patients themselves—for solutions to oral health disparities. Even the American Dental Association (ADA) in its Code of Ethics (under the section devoted to justice) lists only one tangible duty vis-à-vis the problem of access: “[T]his principle expresses the concept that the dental profession should actively seek allies throughout society on specific activities that will help improve access to care for all.”
Dentistry has a long history of disconnectedness. Throughout its existence, it has been practiced largely in separation from other branches of medicine. Whereas the traditional medical disciplines of internal medicine, surgery, and obstetrics gradually merged, dentistry remained a separate discipline. Before the very recent emergence of podiatry and optometry, the teeth were the only part of the body that always retained its own group of healers; all the other body parts, organs, and organ systems were treated by medically trained healers.
This isolation of the oral cavity from the rest of the body has had far-reaching consequences. Dental education is largely separate from medical education. Dentists and physicians have separate licensing boards and regulations. Dental and medical insurance plans are organized separately, and in many countries dental care is not part of publicly supported health care financing systems. For example, the US Medicare program, which makes health care available to the elderly, does not cover dental care. Moreover, as the ADEA points out, dentistry’s disconnectedness “gives the impression to other health professionals, policymakers, and the public that oral health is not as important as general health.” It may even be that many dentists themselves are less appreciative of the importance of oral health compared with medical care and perhaps consider themselves as less important than physicians.
Structural forces at work in dentistry foster these patterns of isolation. Most physicians, even those with private outpatient practices, tend to work closely with other physicians in clinics and hospitals. They cooperate with a diverse cadre of other professionals such as nurses, physical therapists, clinical psychologists, and social workers. Dentists, on the other hand, generally work in relatively small practices that include a few hygienists and dental assistants. They clearly like that way of practicing, as evidenced by the persistence of this practice model. Dentists like to be their own bosses, run their own offices, and practice dentistry their way. They tend to be suspicious of protocols and use reviews, practice standards, professional regulations, and governmental control.
At the same time, many citizens in the United States suffer unnecessarily from treatable and even preventable oral conditions. In turn, this lack of care leads to significant economic losses because of missed days of work, and, in the case of children, far too many missed days at school. More serious still are delays in the diagnosis of oral cancer, leading in extreme cases to premature death. The problem of disparities in oral health is exacerbated further by the unevenness of their distribution. Everyone in the path of an earthquake or tsunami is subject to devastation, but the unmet needs for oral health care are distributed disproportionately because of poverty, race, or co-morbidity.
Other Symptoms of Disconnectedness
The authors submit that dentistry’s relative failure to tackle the problem of oral health disparities head-on is only one symptom among many. They also see dentistry’s isolationism reflected problematically, for example in dentistry’s reluctance to engage in and submit to constructive peer review. Internal regulation is a hallmark of any profession. Dentistry has been less forthcoming than most professions in developing effective peer review programs.
Another example of dentistry’s disconnectedness from society concerns the aforementioned widespread aversion to policies and treatment protocols. The individual dentist, however, is no longer able to stay abreast of rapid scientific and technological advances, and there is the grave risk that a failure to do so will undermine the public’s trust in the profession of dentistry. A case in point is the 1997 Reader’s Digest article, “How Honest Are Dentists?” The article described the experiences of a journalist-patient who visited 50 different dentists to receive examinations and treatment plans. The results showed that the treatment plans varied greatly, as did the costs, which ranged from $500 to $30,000. The article—and even more so the magazine’s cover title, “How Dentists Rip Us Off”—certainly outraged dentists, but it also was unsettling to patients.
There are other signs that dentistry’s high ranking by the public as a trusted profession is faltering. A 2001 monthly column by Gordon Christensen in the Journal of the American Dental Association noted the weakening of public trust and attributed it to the public’s perception that dentists are preoccupied with making money and with their own interests. Also of concern is the recent flurry of very serious cheating scandals involving many United States dental students.
Finally, the authors believe that the ever-increasing practice of commercial competition between dentists, as evidenced by advertising, in-office product sales, and an ever-greater emphasis on elective treatments, is driven at least in part by dentistry’s tendency toward disconnectedness. Some observers within the profession believe that what is at stake in this most onerous demonstration of isolationism is nothing less than the transformation of dentistry from a profession to a business.
Dentistry cannot have its cake and eat it too. Dentists cannot claim professional status but operate primarily according to a business model. The public will not accept such ambiguity. Indeed, in the late 1970s, the ADA’s right to professional self-regulation was curbed dramatically when the Federal Trade Commission and the US Supreme Court found that the ADA (and likewise the American Medical Association and American Bar Association) was a trade organization, primarily aimed at the business interests of its members, and therefore could not prohibit advertising.
More recently, despite vigorous opposition by the dental profession, state legislatures passed various laws on the credentialing of foreign dentists and dental auxiliaries in an attempt to increase access to oral health care services. Some states now are preparing regulations for a whole new cadre of oral health practitioners. In 2006, the ADA failed to block an access-to-care plan operated by the Alaska Native Tribal Health Consortium. Furthermore, there now are published (although challenged) reports about the acceptable quality of care in the Alaska program.
The points in the previous paragraph illustrate that the profession and the public are at odds about a very important issue, and the profession’s view is not prevailing. Arguably, dentists either must respond more effectively to the needs of the public or pay the price of decreased public esteem and trust. The next section shows how to deal with these problems in a way that capitalizes on the profession’s thoughtful evaluation of itself.
Establishing connectedness
If disconnectedness is the problem—or at least a significant part of the problem—the obvious solution is to foster its opposite. What is needed, in the words of Hershey, is “a willingness to be connected —a willingness to go beyond the isolation of narrowly interpreting one’s professional role to be connected to the concerns of other individuals and to the overall well-being of society.” The literature is replete with terms that capture this sense of “connectedness”; among them are “belonging,” “civil engagement,” “community spirit,” “community mindedness,” “public conscience,” “social responsibility,” and even “cultural competence.” The authors submit that if dentists acquire a more robust sense of connectedness, it will be an important first step in the reduction of oral health disparities and other social problems of the profession. In addition it will render dentists more inclined, comfortable, and capable, as stated by DePaolo and Slavkin, “of meeting the nation’s need for oral health professionals engaged in the practice of clinical oral health care, public health practice, biomedical and health services research, education, and administration and who can contribute to the fields of ethics, law, public policy, government, business, and journalism.”
Four Realms of Connectedness
Even if organized dentistry has a long history of contributing to the isolation of its members, and even if individual dentists willingly seek some degree of isolation, most dentists increasingly are cognizant that good oral health care demands connectedness. The days in which the dentist paternalistically could decide what patients need without involving them in the decision are long gone. Patients must inform their dentists honestly about their needs, symptoms, habits, fears, and expectations and in turn must be fully informed by their dentists about their diagnoses and treatment options. Dentists must diligently foster their patients’ trust by maintaining confidentiality, allowing them full access to their records, and abstaining from any behaviors that could jeopardize patient trust. Just as patients must respect the professional autonomy of dentists, realizing that they cannot demand treatment, so dentists must respect their patients’ autonomy and always obtain consent before initiating treatment.
These examples all underscore the importance of connectedness between dentist and patient. There is widespread acknowledgment today that a strong fiduciary relationship, in which the patient is a full partner in the therapeutic process, is essential for successful outcomes. This understanding of connectedness, however, is limited to the sphere of dentists and their particular patients. The kind of connectedness that Hershey and DePaolo advocate goes beyond the dental office. Besides a commitment to their patients, connectedness can be broken down into three additional realms: (1) the profession that dentists choose to be part of; (2) the community in which they practice; and (3) the society at large with which the profession has an implicit contract.
Nothing in this analysis is radical or even new. These three additional realms of connectedness already are acknowledged, even if not as explicitly and robustly as they should be. Consider, for example, the issue of professional commitment. The very definition of a “profession” is intrinsically a social concept:
Many individual expert service providers are committed to serve others and may have even promised to do so publicly. But the social phenomenon of a profession always refers to a collective. It does not make sense for anyone to claim the status of a professional if there is no profession to which one belongs. Indeed, society’s trust in professionals is not vested in the individual service providers but in the profession at large.
Furthermore, many dentists already assume leadership roles in their communities and apply their specific expertise and skills for the betterment of those communities. Their engagement ranges from health education projects in schools to the provision of oral health care for the homeless, and from lobbying for water fluoridation to serving in elective office.
Many dentists likewise exhibit deep concern for the well-being of society at large and understand the importance of cooperating with other players in society. Public health dentistry is an acknowledged specialty today and indeed is a concern of every dentist. The ADA’s code of ethics specifically states, “[T]he dentist’s primary obligation is service to the patient and the public-at-large” (Section 3). More recently, environmental protection has come to the foreground. As Mandel points out, “[D]ental practice today involves a growing list of safety concerns that are important areas for discussion—as well as oral health research—and include infection control, radiation safety, mercury hygiene, amalgam and silver halide disposal, waterline biofilms, and nitrous oxide leakage and its reproductive effects.” Access to oral health care is yet another issue of concern.
If dentistry is to overcome its historical tendency toward isolationism, and if one grants that dentists must develop a more robust sense of connectedness not only to their own patients but also to the profession of which they have chosen to be part, to the community in which they will be practicing, and to society at large, then practitioners themselves must take the first step.
Practitioners as Agents of Change
The history of how professions, dentistry included, are formed is a story of grassroots leadership by dedicated practitioners over long periods of time that results in society’s recognition of their particular expertise as being worthy of public trust. It begins with the practitioners of a given occupation coming together to form associations. Working within that framework, the early practitioners recognize that their survival depends on their credibility. The recognition of their credibility by the public is accomplished over time through the requirement of formalized training and ultimately by the granting of licensure. Gradually the professional associations become powerful enough to acquire legislative recognition by the government. This recognition gives the aspiring profession competitive advantages in the marketplace, permitting its membership to function effectively as a monopoly.
The evolution from occupation to profession comes about only if practitioners can gain the public’s trust, and that trust is given only if (and as long as) services are provided with dedication and a sense of integrity. Ultimately, professional status is not a right but a privilege awarded by society. In a similar vein, the ADEA in its 2003 report, “Improving the Oral Health Status of All Americans: Roles and Responsibilities of Academic Dental Institutions,” reminds dentists that “knowledge about oral health is not the property of any individual or organization; rather, society grants individuals the opportunity to learn at academic dental institutions with an assumed contract that this knowledge will benefit the society that granted the opportunity to obtain it.”
How did the early profession of dentistry gain this trust? Much of dentistry’s crucial history occurred nearly 200 years ago, in the 1830s, a time of great instability in the national experience. Financial speculation was rampant. Banks failed, and bankruptcies were common. Unemployment was rampant. At that time American dentistry existed without any well-established system for either education or oversight, even though many dentists were quite competent as a result of the limited apprenticeship training that was available in various places. Because of the absence of standards for entrance to the practice of dentistry, however, anyone who chose to do so could engage in dental practice. In the 1830s, as a result of widespread unemployment, many out-of-work persons viewed dentistry as a golden opportunity to make money in a very short time. By arranging individual agreements with dental practitioners, farmers or shop men could move from the farm or the factory to the dental chair within a few months, often within a few weeks. As a result, the ethical practices and overall competence of dental practitioners took a tailspin, and public concerns about the quality of care rose accordingly.
A potentially disastrous situation for both the public and for dentistry was averted because leaders came forward from the ranks of practitioners and worked diligently in the public interest against their unscrupulous colleagues who were practicing unorthodox remedies and who had no compunction about using aggressive advertising to promote them.
This leadership culminated in three key developments: the publication of the first dental journal in the United States, the creation of the Baltimore College of Dental Surgery in 1840 (the world’s first dental school), and the formation of the American Society of Dental Surgeons (the first national dental society), also in 1840.
Each of these events was a necessary milestone in the recognition of dentistry as a profession. Without the creative leadership of dedicated practitioners in the early decades of the 1800s, dentistry’s movement toward recognition as a profession almost certainly would not have occurred for many more decades to come, and its development might well have been far less auspicious than it has been.
At present, the country is once again in deep financial distress. Unlike the 1830s, the profession of dentistry seems to be thriving. There are, however, cracks in the profession’s foundation that represent serious challenges to its future. The next section details a plan for meeting these challenges that, like dentistry’s actions in the 1830s, should be led by the practitioners themselves.
The Scope of Planning
The plan presented here offers practical suggestions for developing connectedness in the professional lives of dentists. The authors believe this sense of connectedness can be achieved through a continuous process of critical self-definition. They encourage each individual practitioner and the organizations to which they belong to define for themselves the kind of professional person they and their colleagues should be, by responding to a series of questions designed to reevaluate professional values (see Appendix 1 ). The answers to these questions will differ for different groups, reflecting differences in community experiences both for the profession and the public, regional oral health needs, and regional cultural influences. This is a period of changing values, both for society at large and for dentistry. As traditional values are challenged, dentists must be aware of the historical and cultural influences that surround them.
The authors take their prototype for reorientation from that used by the Bon Secours Health System, Inc. (BSHSI) of Marriotsville, Maryland. The BSHSI developed its format decades ago as a way to revitalize its organization and present itself more favorably in a competitive marketplace. Its current Ethics Quality Plan 2005 is “intended to take BSHSI to a higher level of ethical awareness, expertise and behavior.” Its goals include ensuring (1) that “excellence in ethics” is a BSHSI hallmark, serving both clinical and organizational needs; (2) that BSHSI “is capable of meeting the challenges of [the] future; and (3) that both “leadership and co-workers develop a suitable understanding of ethical issues and consistent habits of acting ethically.”
The BSHSI plan differs from many other such institutional statements about ethics and values in its implementation into everyday activities. BSHSI takes the process seriously. It uses the process to guide the routine function of its health care system (James DeBoy, Vice President, Mission, BSHSHI, personal communication, June 6, 2005). All its institutions post their mission and values statements in conspicuous places. Each new employee is familiarized with its values, and each year the values are reinforced during staff meetings. In fact, the values are so much a part of the institution that they permeate all its decision-making processes, from clinical care to the making of budgets.
The authors present this plan with no illusions. Re-evaluation of life’s directions never is easy, but dentistry’s professionalism and its value system area at stake. If the profession wants to see changes in access to care and other serious issues, it must re-evaluate what dentists and dentistry ought to stand for and to judge how close they are to meeting those standards. The process, however difficult, will be interesting and certainly rewarding.
Leadership and Key Players
As with the grassroots activities in the 1830s, leadership must come from practitioners working through their various dental associations. Presumably, the primary organizations with which to collaborate are the state dental associations because of their broad representation of the profession. Other organizations to consider include the American College of Dentists, which has ethics and professionalism as a primary focus, and the Academy of General Dentistry, which also has a history of concern for ethics. Similarly, the various state boards of dental examiners have a vested interest in the ethical direction of the profession, as do specialty organizations.
Ideally, the process described here would take place in multiple communities all across the nation. Depending on the geographic context, the locus of such action may be as large as a whole state or as small as a city. Groups of two or three concerned dentists could work to persuade their organization to undertake the project. To maximize success, a broad base of key contacts should include the president, members of the board, and members of key committees or councils that pertain to issues germane to this project. These committees might include those dealing with charitable activities, peer review, governmental relations, and ethics and professionalism, among others.
If the organization is interested in participating, there should be opportunities for discussion in general forums such as the annual meeting of the association. The goal of these discussions is to inform the membership about the project and to generate support for it.
The actual work would be done by a committee composed of 18 to 20 individuals. Committee membership would consist, in part, of officers of the organization, members of pertinent committees, and representatives from the general membership. In addition, because such a project has implications that go beyond the profession, other groups should be represented as well. Examples include a member of the board of dental examiners, the state department of dental health, non-dentist members of the dental team, physicians, and representatives from the general community. In addition, if there is a nearby dental school, one might consider including representatives from the student body and dental faculty.
The entire committee would meet initially for the purpose of general orientation. It then would be divided to function as two small groups during the data collection phase, which consists of discussions of challenging questions about the committee members’ views concerning the ideals, values, scope, and obligations of the dental profession.
Questions for Discussion: The Heart of the Process
The questions to be raised are by far the most important component in this process. The small-group discussions are led best by someone with experience and skill in working with diverse groups. In the discussions, it is essential to nurture a climate in which everyone feels comfortable in expressing their views, including views that are unpopular, without the risk of disapproval. Discussion leaders should try to summarize the views expressed on each question. When disagreement occurs, the discussion leaders should determine the point at which disagreement occurs.
Collectively, the questions should help the organization define its vision of how dentists should function as professionals as they interact with their patients, their profession, their community, and society in general. From the responses to these questions, value statements, as described in the next section, can be established that reflect the beliefs of the committee about what constitutes professionalism. At this point, the two separate committees combine in an attempt to prepare a final document. Ultimately, the agreed-upon value statements are presented to the membership at large for ratification.
Suggested questions for discussion appear in the Appendix at the end of this article. The questions are adaptations from papers by the present authors on the role of dental schools in the development of professional values, but each organization is encouraged to edit these questions freely and to create new ones according to its needs.
Using the Information
Guiding value statements should be developed based on the information collected during discussion of the questions by the small groups. Each completed value statement should include three components: (1) a characterization of the essence of the statement in a single word or a phrase that serves as a lead-in to a full statement; (2) a definition of the value; and (3) an illustration(s) that includes a descriptive interpretation of its practical applicability. For example, if a particular organization decides that the altruism is part of its identity, altruism could be defined as “placing the interest of the other above one’s own interest.” The descriptive interpretation could be “Dentists as professionals recognize their own interests but strive to keep them in perspective as they recognize the vulnerability of their patients. They especially recognize the interests of those who need care and, with their colleagues, look for appropriate ways to contribute to those persons’ well being.”
Once the data have been collected and processed, the value statements need to be ratified by the organization. The organization then needs to put the values it has endorsed into action. The authors offer the following suggestions for helping the organization act most effectively:
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Establish a committee that will both monitor and promote the program
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Inform all existing and new members of the organization about the program and the organization’s commitment to it. Effective mechanisms of communicative may include the organization’s Web sites and print media
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Compile a list of examples for members to act upon, beginning with the examples that are presented in the descriptive interpretations of the value statements
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Catalog the activities of the membership in professional, interprofessional, or community activities for appropriate use within the organization or for public relations
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Formulate policies that foster participation in collaborative efforts with medical or other health disciplines
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Encourage collaboration with nearby dental schools in projects of mutual interest, such as participation in the teaching of ethics or in community-oriented projects designed to reduce oral health disparities
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Support initiatives that affect general societal welfare, including public health initiatives and other societal measures of merit, such as those involving public nutrition, environment, ecology, or racial discrimination
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Encourage members’ participation in non-dental community outreach groups, such as Big Brother or Big Sister organizations or those that focus on HIV, juvenile diabetes, church outreach, or soil conservation.
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Celebrate the leadership of the organization’s members, both individually and collectively, in worthy causes
To initiate and carry out the process described is a challenging endeavor. It should not be undertaken, however, without considering how to assess its impact—an even more difficult challenge. A recently published article by Patthoff proposes an interesting self-assessment system that members of professional organizations might wish to consider. In fact, this program already is in the process of being developed. Its goal is to help practitioners build ethically sound practices. It is patterned after the Baldrige Awards, which were created by Congress in 1987 to recognize outstanding quality and performance in the business world. The basic idea of the Baldrige process is to use voluntary self-assessment in seven categories of business activity, ranging from leadership to customer and market focus. Adapting the Baldrige process to the needs of dentistry requires a significant reorientation. As Patthoff points out, its “purpose would be to advance professional ethics rather than gaining a ‘competitive edge.’” Thus, in dentistry issues such as fiduciary relationships would be considered, along with collegial cooperation, community interaction, and social engagement.
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