The Obligations of Dentistry’s Professional Organizations
You have recently become editor of the prestigious (and fictitious) American Journal of Dental Prosthetics, the official publication of the (also fictitious) American College of Fixed and Removable Prosthodontics (ACFRP) and a leading journal within the American dental community. You were appointed editor in chief of AJDP because of years of hard work, careful teaching, and significant research. You now face an important decision about advertising in the journal. Your managing editor and your chief associate editor, who have been with the journal for years, are seated before you. They are deeply divided about an expensive, full-color, four-page ad that the Peterswill Corporation wishes to place in AJDP for its new product, Capwright.
Peterswill has been a leading producer of dentifrices and other oral hygiene products for years. Its advertising has been a mainstay of AJDP, and the Peterswill Foundation, heir to most of the fortune of the company’s founder, Peter Roundsmith, has long been a major supporter of ACFRP programs. But the Peterswill Corporation has gone through some difficult years recently. Sales of its mouthwash declined significantly after federally mandated changes were made in Peterswill’s advertising claims, and the firm’s share of the dentifrice market also slipped badly, chiefly because of the corporation’s complacent attitude toward fluoride research. Now a new senior management group is in place, trying to turn things around by expanding Peterswill’s markets. Their new senior researcher, hired away from a competitor, has developed Capwright. The firm’s management believes that Peterswill’s ability to survive now rides on the success of this product.
Capwright is a bonding adhesive and cementation seating compound for fixed prostheses. Its appeal lies in its claim of being durable years longer than any current cementation or restorative product on the market. It also claims and presents data that it adheres to all dental, metal, glass, and composite surfaces, both in the preparation of and in the seating of the prosthesis itself. It appears to be capable of filling any gaps that might occur between the two surfaces without weakening the bond, thus making up for errors in a dentist’s preparation of the tooth or in the impressions that the dentist takes for the prosthesis and some other possible errors in the transfer models and fabrication processes.
The ad copy from Peterswill’s advertising agency doesn’t make this point quite so explicitly, of course; it stresses Capwright’s “potential to expand the general practitioner’s ability to place caps and bridges while giving even the most expert prosthodontist new confidence that his or her appliances will seat perfectly.” But any dentist who reads the ad will understand what is being inferred.
The chief associate editor speaks first: “The first thing you have to ask yourself, Doctor, is what it means to say that we are professionals. We claim to be committed to quality treatment and to placing our patients’ oral health ahead of our own desire for money and a flourishing practice. There isn’t any doubt that quality treatment and the best care for our patients means that teeth must be properly prepared for prostheses. Impressions, imaging, castings, and all fabrication procedures must be done with precision.”
“What do we teach our students in the dental schools?” the associate editor continues. “Certainly not to just come close and then fill in any gaps that are left with a good cement. We teach them that an exact fit is expected from preparation to prosthesis. We teach them the skills to carry this out in routine cases, and we expect them to refer more difficult cases to specialists because that is what the standard of care requires.
“If that is true, then how can this journal publish an ad like this, which says to general practitioners and specialists alike, ‘Don’t worry about your sloppy work. We’ll cover your mistakes!’ This journal has a reputation to protect. That’s one thing, and I think it is important. But something more important than that is at stake. We are a profession. We hold a public trust, not just as individuals but collectively through organizations like the college. If Capwright is a superior bonding agent, or if it is better at handling the microscopic imperfections that occur in even the highest quality prosthetic preparations and castings, let them say that and provide the long-term clinical research to prove it. We would be guilty of a serious violation of our professional ethics and we would be sending a terrible message about our profession if we were to publish an ad that encourages dentists to tolerate substandard preparations because they can cover up the results with Capwright!”
The managing editor responds: “Of course I respect the values that the associate editor refers to, but there are four additional facts that you need to take account of in your decision, Doctor. First of all, there is the financial issue. We rarely get a chance to run a full-color four-pager, much less to have a chance to contract for one each month for the next two years. Besides, Peterswill has been one of our major advertisers. There is good reason to think that the firm’s new management would pull their other advertising from the journal if we refused to run the copy for Capwright.
“You know as well as I do that if the only funding we had was the grant from ACFRP, this would be a quarterly journal of forty or fifty pages, not a monthly that has room enough to serve our community in dozens of important ways on top of the first-rate research we publish. We can’t ignore our advertisers and still serve the members of the college and the larger dental community. They are depending on us. That’s the second point. In addition to our own bottom-line considerations, we have an obligation to continue serving our readership because they need us and count on us for all that this journal does for them.
“In addition, this product has been field tested by reputable laboratories. It has FDA marketing approval for what it is claiming. So far as the FDA and we know, it won’t harm anyone’s teeth any more than products in current use and it won’t compromise patients’ health. The associate editor says he would be willing to advertise a product that claims to fill in microscopic imperfections. Well, we all know that there are many general dentists out there who prepare prostheses with more than microscopic imperfections in the fit, and some patients eventually pay the price in sensitivity, pain, and/or lost function. Why not encourage the general practitioner to use a product like this that will raise the quality of the general dentist’s prosthetic work? It is the GPs who are the most pressed right now, with the economics of dentistry changing so much. Don’t we owe them some consideration?
“Besides that, this journal isn’t published just for the members of the college. The journal says it serves the whole dental community. That’s its mission. In the name of the college it’s trying to educate dentists generally about good prosthetic care. Here is a way that the care that ordinary dentists actually give their patients can be significantly improved. The standard of care in the dental schools is not the standard of care out in the offices, and it is that standard of care that we have a chance to improve here.
“Finally, I want to ask whether the editors of this journal are the ones who ought to tell practicing dentists what is and what is not appropriate care. Dentists are professionals—the associate editor has already stressed that point. But that means they are the ones that have been entrusted with making decisions about the proper care of their patients. Each of them must make that decision about each particular patient. We cannot make those decisions for all of them. Our job is to inform them of the clinical techniques available to them, and you know as well as I do that our advertising is as important a vehicle for doing that job as our articles on current research. This product has FDA marketing approval and is the result of extensive research in Peterswill’s own labs and at several universities. So I submit that we would be going beyond our mandate, and doing a disservice to the dental community as well, if we refused to publish this ad, not to mention tightening the financial noose around the journal’s neck instead of taking the opportunity to let it take a deep breath for the first time in years.”
You are the editor in chief, Doctor. What should you do?
To this point, this book has principally emphasized the obligations of chairside dentists because of the commitments they have made in becoming professionals and because of the nature of the profession they have joined. But each profession as a whole also has obligations, and so do its professional organizations. This chapter will examine the obligations of the dental profession as a whole in our society and especially of its professional organizations, for these play important roles in the ongoing dialogue between the profession as a whole and the larger society.
First, however, the general idea that organizations and even a profession as a whole organization can have obligations deserves some examination. The cultural bias mentioned in chapter 4 that views all judgments and choices as the actions only of individual humans, rather than seeing some of them as the actions of groups of people acting as a unit, can easily get in the way of our thinking about obligations in regard to groups of people. But groups of people working together collect data, process it, examine alternative courses of action, make judgments about how to act, and then actually do things. When individual humans do these things, under the proper circumstances, we have no trouble thinking of them as actors and as having obligations. There is no good reason, in the authors’ view, why we shouldn’t understand organizations to be actors that have obligations in the same way, and in fact, many people who look at how various organizations act are quite ready to say they acted wrongly or, sometimes, admirably. That is, organizations are often viewed as having obligations.
What may be less obvious is that groups that are not formal organizations and do not have established roles and offices (i.e., what might be called “informal groups”) can have obligations. Among these, for example, would be groups of friends, larger groups like the people at a political rally, and also the whole people of a nation. Such groups can have characteristics in common that, when exercised collectively, give the group the ability to collect data, compare alternatives, and select actions that are rightly considered to have been performed by the group. The dental profession as whole (within a given society) is such a group, and under proper circumstances it is rightly—by analogy with individual actors and formal organizations—considered to act as a single actor and to be responsible for what it does. That is to say, it can have obligations.
It is beyond the scope of this book to delve further into the arguments that philosophers and other social theorists have made for (and against) the idea that groups can perform actions and have obligations. It is, however, a premise of this chapter that the dental profession in our society and its professional organizations have obligations. Therefore, it is important to reflect on what these obligations are.
Of course, groups of humans function as actors—gathering data, evaluating alternatives, selecting among them, and acting—only by virtue of and by means of the actions of the individuals who make up the group, and these individuals therefore have whatever obligations come with the roles they play. But this fact does not mean that a listing of all the individual actions involved will be enough to completely describe what is going on in such a situation, without anything missing. Part of what is meant by saying that a group acts and has obligations is that, even after all the actions of the individuals involved have been thoroughly described, there will still be more to say about what the group as a whole does and ought to do.
But because such a group acts only by virtue of and by means of the actions of individuals, it follows that the group cannot fulfill its obligations unless the relevant individuals, playing various roles within it, act as they need to so the organization acts as it ought to. This means that every member of the dental profession has, by reason of membership in this group, an additional professional obligation to do what is necessary so that the profession as a whole acts as it ought. Similarly, and especially, since it is dental organizations that most often represent the dental profession as a whole in our society, every professional dental organization and every member of these organizations has an obligation to act in ways that support dentistry as a whole and each of its professional organizations acting as they ought.
Exactly what an individual dentist ought to do to fulfill these obligations will depend on many factors in the dentist’s professional and personal life. Some of the obligations of the dental profession as a whole, for example, are such that individual dentists work most effectively to fulfill them by their actions and what they communicate about the dental profession day in and day out at chairside and, as the previous chapter stressed, by what message this sends to the larger community about what dentistry is committed to and stands for as a profession. For whether a dentist is reflective about it or not, he or she is continually and unavoidably acting in the name of the profession as a whole. Every act of a dental professional organization, whether the members or leaders of the organization are reflective about it or not, similarly communicates a message (either positive or negative) about the dental profession as a whole and what it is committed to and stands for. This fact means that individual dentists (and nondentist staff) who are active in dentistry’s professional organizations have obligations to make sure the organization is acting ethically—not only by the minimal standards of organizations in the marketplace but by the norms of professional dentistry—and that its message to the larger community about the dental profession is a positive one.
As every dentist knows, the extra burden of being active in organized dentistry cannot be made to fit into every professional life in the same way. Most dentists find some times in their professional lives more suited to playing an active role in dentistry’s professional organizations and other times—for example, when their children are younger and their practices are not well established—less suited for the demands of such activity. But because of the importance of the actions of professional organizations in the public’s view of the profession, no dentist may ethically look on the activities of dentistry’s professional organizations simply as matters that “someone else” is responsible for. At some appropriate point, every dentist ought to be active in shaping the actions and policies and contributing to the activities of organized dentistry in other ways. This is an important element in the collective life of dentistry as a whole and is a major contributor to the larger society’s continued conviction that dentistry is a profession. That is, every dentist bears a share of the responsibility for the character of the dental profession as a whole. Every dentist must take seriously the obligation to shape that character from within dentistry’s professional organizations as well as representing the whole dental profession in how he or she practices at chairside.
What obligations does the dental profession as a whole have and what obligations do dentistry’s professional organizations have? The nine categories of professional obligation introduced in chapter 3 and employed in the discussion of chairside dentists’ obligations throughout this book can be used to offer answers to these questions.
One of the most important roles of the dental profession in our society is its contribution to the society’s understanding of what counts as oral health and what indicates its absence, especially with a view to professional intervention. As will be explained, the profession’s obligations in carrying out this role require consideration of three different categories of professional norms—namely, Chief Client, Central Practice Values, and Competence.
The most general meanings of the concepts of health and disease are probably fairly consistent across cultures and eras. But as these meanings are specified more concretely and grounded on more and more concrete understandings of desirable human functioning, the distinctive values of a given society’s culture and even of the accepted modes of practice of each particular health care profession become incorporated into them. Thus, what counts as Oral Health in a particular society like our own is not something timeless, though it seems connected to or is a specification of something of lasting and general human value. Instead, its functional content has been determined in large part by cultural conceptions of acceptable versus unacceptable levels of pain/comfort and function/dysfunction. These, in turn, are significantly affected by the interventions that are performed by those considered expert in the society in addressing and modifying people’s oral pain/comfort and function/dysfunction.
Those who play this role are the society’s dental professionals both when acting as individuals and through the actions of dentistry’s professional organizations, for the interventions that dentists judge appropriate to perform at chairside or that dental organizations recommend for chairside use do not include all possible interventions that might be performed in, on, or for people’s mouths. The dental community considers only certain types of possible interventions constructive for Oral Health, so the dental community, to a significant degree, determines what counts as appropriate and pain-free oral functioning (i.e., Oral Health) and what counts as oral dysfunction.
At the same time, however, which classes of interventions are considered proper is also partly determined by the larger society’s values regarding oral pain/comfort and oral function/dysfunction. Thus, these two groups—the society’s dental professionals and the community at large that carries and shapes its culture—work together in subtle, ongoing ways to shape the concept of Oral Health and its absence, and these concepts, in turn, guide the practice of the former and the expectations of the latter.