3

CASE: WHEN EVERYTHING WORKS RIGHT

George Anderson, a thirty-eight-year-old plumber, has diabetes and is under the care of his physician of seven years, Dr. Gannett. At his last visit Dr. Gannett told him that the on-and-off pain in his teeth could be related to his diabetes and that he should see a dentist. Dr. Orasony is the first dentist Mr. Anderson has seen since his “kid-dentist” referred him, in his early twenties, to an oral surgeon for his wisdom teeth. “I want all these teeth out,” Mr. Anderson says to Dr. Orasony. “I need some plates to replace them. There’s nothing I can do about this diabetes. I know myself. I’ll never be able to follow the diet my doc says I have to for the diabetes.

“Dr. Gannett’s always bawling me out,” he adds, “so I don’t go to see him; then he yells at me for that . . . or for not testing my blood sugar often enough or for something else. I do my insulin shot every day. I’ve got to or it’ll kill me.”

Dr. Orasony takes a quick look and notes several carious lesions, the upper-right second molar will likely need endodontics, and there is significant bleeding and swollen gums with mild localized recession and poor oral hygiene. When asked about his oral hygiene, Mr. Anderson says, “I brush a few times a week, when I think about it. I hate flossing . . . takes too much time. Makes ’em hurt and bleed and doesn’t do any good.”

“Despite what’s in the news lately, flossing is important for anyone with teeth,” says Dr. Orasony. “But for people with diabetes, I’m convinced it’s absolutely necessary. Diabetes affects the body’s natural repair system. It takes more self-care to help damaged gums stay healthy. I’ll need to take X-rays and do a few measurements, but right now I’d say most of the pain in your teeth is probably from the damaged gums. Good brushing and flossing are critical for keeping down the plaque buildup on our teeth—the white fuzzy stuff we feel with our tongues. There are a few simple tricks to good daily mouth care. Careful instruction on how it’s done and why it’s so important takes a little time and some follow-up, but it’s well worth it.”

“My old dentist talked about that when I was a kid. That was when he said my wisdom teeth were causing my pain. Once they were out, I felt fine, so I didn’t go back. Then he died.”

“So you haven’t seen a dentist since you learned you had diabetes?”

“Nah. After my wisdom teeth were pulled my teeth felt fine,” says Mr. Anderson. “I’ve had dental insurance from work for a long time but never used it ’cause my teeth felt ok.”

“Well, your diabetes really changes things, and the pain you’re having is a sign of that. It’s important that you start seeing a dentist regularly from now on. We’ll help you learn how to take better care of your mouth, or you’ll have a lot more problems than you have now. Your gums are already affected, but the damage seems only moderate and likely can still be fixed without major surgery. The most important part will be your changing the way you care for your mouth—and yourself.”

“Yeah, but it’s hard to do stuff like that, a lot harder than just taking a shot,” Mr. Anderson says. “It sounds just like the diabetic diet. Don’t you have a shot for the gums, too? I like things quick and dirty.”

“It’s hard,” says Dr. Orasony. “Diabetes is a real bummer. You’ve got my sympathy.”

“Well, what about just yanking them out and giving me the plates?” asks Mr. Anderson. “Won’t that solve the problem and save us both a lot of grief?”

Dr. Orasony then carefully explains the long-term risks of this option and the reasons for keeping and maintaining natural dentition for as long as possible. “I hate taking such drastic action,” he says, “I only consider taking teeth out in extreme cases—and rarely in someone as young as you.

“Still, your situation is a hard one,” he says, “but it’s not out of your control if you’re willing to work at it. With the proper diet and oral hygiene that we can teach you, you really can manage the effects of the diabetes on your mouth. We’ll work with you every step of the way.”

“I’m not so sure,” says Mr. Anderson. “I haven’t done very well with the diet and the other stuff so far, only the shot ’cause it’s simple and I know I need it.”

“Well, why don’t we try to change things now,” says Dr. Orasony, “because you need these other things, too. I hate to be so blunt, but a bad diet will kill you just as surely as missing your shot will—it just takes longer. I’m not saying we’re going to live forever, just that (speaking for myself) I’m more comfortable when I’m taking care of myself and feeling healthy than when I’m not. We all need to make a habit of good oral hygiene, especially in your situation, or your mouth will give you more trouble than it is now, and eventually that will lead to a lot worse problems.”

“What should I do?” asks Mr. Anderson.

“To start with, after we get some measurements on your gums, you’ll need several appointments to get your teeth properly cleaned, especially around the gums so they can start to heal. It doesn’t look like it’ll involve any surgery, though that is a minor possibility if it turns out that a good cleaning doesn’t do the job. You also have several cavities that’ll need attention once your gum situation is under control. There’s one big tooth in the back that may need the tissue down inside it treated to save it—that’s what’s called a root canal. We’ll need some X-rays before I can say what will actually be needed there. The most important, though, is the first step—the instructions and then the follow-up on your daily brushing and flossing. You’ll have to make a habit of that. Now, I’ve said a lot and we still need to do the exams. But I want to be sure I’m not being confusing. Is what I’ve said clearing things up for you?”

“I’m not surprised I need some things done. I mean, it’s hurting and all. My union health insurance is pretty good for dental work, so I’d say let’s go ahead and see if it helps. Since I’m already here, can we start now?”

“I’d really like to. The first step is getting X-rays and the needed measurements before the dental hygienist, Miss Williams, starts the cleaning. Then she’ll check with me, but she’ll probably start the cleaning today, taking off that buildup on your teeth, especially around the gums. That’ll help your gums feel better so you can brush and floss daily without the pain and bleeding. Miss Williams will go over some basic instructions about that before you leave today. She’ll probably need a second appointment to finish the cleaning, though, so we can see whether other work might be needed to help your gums heal. Once that’s under way I can start fixing the cavities. You mentioned on-and-off pain from your teeth. From what you’re saying and from what I’m seeing, it’s probably more from the gums than the cavities. But if you get more pain from any tooth or a throbbing anywhere, call me so we can fix it right away. Also, if your gums don’t respond to the basic cleanings, we’ll need to decide about gum surgery, so I need to mention that, and that may mean referring you to a specialist. There are several gum doctors—they’re called periodontists—whom I work with here in town. But that’s a bridge we don’t have to cross now. Does this work for you?”

“It’s fine. I’m just not sure I’m gonna do my part,” says Mr. Anderson. “I wish you could just take care of it all. It’s like the diet. I wish they just had a shot you could take instead of all that other stuff.”

“When Miss Williams explains the brushing and flossing,” says Dr. Orasony, “you can tell her all your doubts. She’s very understanding and loves to help people fit good oral hygiene into their lives. I think you’ll find the habits you need to build up easier to develop than you expect.”

Dr. Orasony then asks permission to contact Mr. Anderson’s physician so that they can keep each other informed of Mr. Anderson’s progress. The hygienist, Sarah Williams, then completes Mr. Anderson’s appointment and schedules him for a second one two weeks later.

During that time, Dr. Orasony calls Mr. Anderson’s physician, Dr. Gannett, who, not surprisingly, is very frustrated with Mr. Anderson’s health habits, given his medical condition. The two doctors agree that their support of each other’s efforts could be the thing to trigger the needed changes. Dr. Orasony suggests that Dr. Gannett might be the best person to contact a nutritionist and a family counselor he knows at the local hospital to help both Mr. Anderson and his wife set up an appointment with their new program. Dr. Gannett isn’t familiar with the program leaders’ names or the program. “Those two women are phenomenal,” says Dr. Orasony. “I was on a community education panel with them a couple of weeks ago. After their talk, a dozen people surrounded them with questions about changing the way their families talk about things and finding healthier ways for picking and fixing food so all of it could fit into their daily lives. I was very impressed.”

At the second appointment, Miss Williams finishes the initial prophylaxis. She also talks with Mr. Anderson to determine how much he has retained from her instructions at his first appointment and then continues educating him. Dr. Orasony then explains the results of the X-rays and measurements to Mr. Anderson and confirms the treatment plan.

Mr. Anderson appears faithfully for a third and fourth appointment. The gingival tissue responds well. Both Miss Williams and Dr. Orasony see the effects of Mr. Anderson’s brushing and flossing and strongly encourage him about it. Mr. Anderson then thanks Dr. Orasony for suggesting the meeting with the nutritionist and family counselor.

Restorative treatment, including endodontic therapy for one of his molars, is nearly complete by the sixth appointment. Mr. Anderson is clearly establishing a model daily routine of both oral and general hygiene, and he is even starting to take more pride in his dress. Dr. Gannett also calls Dr. Orasony out of the blue to thank him for putting him in touch with the nutritionist and family counselor because they have also helped three other diabetic patients of Dr. Gannett’s to get their diets under control. At his sixth appointment, Mr. Anderson asks Dr. Orasony, “Is Miss Williams in the office? I’d like a moment with both of you before you numb me for these last fillings.”

When Miss Williams walks in, Mr. Anderson says, “I’m glad you’re both here today. Dr. Orasony says this’ll be my last appointment for now. I’ll just be coming in for checkups, and I just wanted to thank both of you for everything you’ve done for me and my wife. It was you and then the nutritionist and family counseling team at the hospital—Liz and Kim—who got us on the right track. We’re sitting down to great meals all together now and the kids are getting to be little gourmet chefs. Our whole family seems to be working together and talking better with each other. I want you to know how grateful we are for everything you’ve done. If not for you two, none of this would’ve happened.”

WHY THIS KIND OF CASE?

Some readers might find it puzzling to find a case like this in a book on professional ethics. There is a mistaken notion that the only cases useful for learning about ethics are either cases that describe some kind of unethical conduct or cases where the ethical issue is complex and difficult to sort out. Why have a case, then, as the title of this one indicates, where “everything works right”?

One reason for giving prominence to this kind of case is to remind us that observing appropriate behavior in someone else and trying to do the same is actually the main way we learn how we ought to act. There can be value in studying examples of unethical conduct, but only if we spend time carefully asking in what ways the action fell short, since this may point us in the proper direction. But simply avoiding inappropriate acts, obviously, is not the same as doing what we ought to do. Even focusing on an example of right conduct does not ensure we can act in the same way, though, if we do not carefully ask what it is about this example that made it professionally and ethically correct. Of course, this case where everything goes right is just a hypothetical example. A better source for learning how to act in accord with dentistry’s professional ethics are examples of actual dentists acting in ethically correct ways and, then, asking ourselves what it is about these actions that makes them ethically correct. It is easy to overlook this resource for ethical growth; examples of dentists doing what they ought to do are so common that they may seem to have little instructional value. Yet every instance of ethical-professional conduct can be a learning opportunity if it prompts thoughtful analysis of the specific characteristics that make it ethical.

One thing that stands in the way of this kind of careful analysis of examples of dentists’ ethical (or unethical) conduct is the assumption that ethical thinking is supposed to be simple and obvious. This assumption is false, although it is sometimes fostered by the way dental ethics is taught and by the way various codes of dental ethics articulate their content—in terms of straightforward dos and don’ts. As mentioned in chapter 1, the codes of ethics published by various dental professional organizations are intentionally brief. They are written to be, as our plumber friend would say, “quick and dirty.” A code can only summarize the most obvious components of the profession’s ethical standards. Of course, they can be useful educational documents because, in many situations, the action that is ethically required is obvious. But dental practice includes many situations in which what ought to be done is not simple and obvious and cannot be determined by referring to a list of simplified dos and don’ts.

Just as a lot of knowledge and skill must properly come together for a dentist’s actions when treating a patient to be technically correct, so, too, are certain elements of knowledge and skill needed for a dentist’s actions to be ethically correct. The difference between these two kinds of knowledge and skills is not that one is simple and the other is complex. The difference is that dental school faculty (as well as the dental researchers in the subfields that make up dental science) have identified and carefully differentiated the various components of knowledge and skill that go into technical proficiency in dental practice. As a result, teachers and students can then focus on them one by one and can then practice putting them together until they gradually become able to tell when they are doing all of them well or if they need more work on some of them in a particular practice setting.

There has been little comparable effort, however, to identify the knowledge and skill components of professional-ethical conduct. The dos and don’ts of codes are not enough. What is needed (and what is also needed by the authors and conservators of codes in order to be sure the dos and don’ts themselves are properly stated) is deeper understanding of dentistry’s ethical norms. For the ethical norms of every profession, when they are fully stated, include at least nine kinds of ethical content, or, to say the same thing in different words, address nine sets of questions about how the members of that profession ought to conduct themselves.

The aim of this chapter is to identify the nine kinds of ethical content that are relevant to the ethics of every profession and then to describe the content of each of these categories of ethical norms as they apply to the dental profession. Then, the rest of this book can use these categories to unpack more concretely what is ethically at stake in different kinds of dental practice situations. After introducing the nine categories in very general language that applies to any profession, the opening case will be reviewed and the kinds of ethical questions identified that Dr. Orasony would have asked himself, or would at least have addressed without noticing it, in order to make “everything work right.” This description of ethical thinking in the case will point out ways in which the nine sets of questions about professional ethics can guide a dentist’s thinking in practice and, taken together, can provide dentists with a clear vision of what to aim for in practice. Note that, in addition to identifying the kinds of questions that dentists ought to ask and the kind of thinking dentists ought to regularly engage in as they practice their profession, the chapter is also providing the tools a dentist needs to analyze the ethical (and unethical) conduct of other dentists as well. Thus, it provides the reader with tools for asking about Dr. Orasony: What is it that makes his conduct professionally ethical?

Briefly stated—in question form—the nine categories of professional-ethical content to be discussed here are: (1) Who is the profession’s Chief Client? (Dentistry and the other health professions have a special word, “patient,” to name the people they serve, but most professions don’t. The word “client” is used by many professions to name those they serve—for example, therapists, lawyers, and architects. It can make what professionals do sound too much like a market relationship, but other than “beneficiary,” which already has a very specific meaning, there is no other generic English word that means “the person or group to be served,” so this book will use “client” whenever professions, generally, are being discussed.) (2) What is the Ideal Relationship between a member of this profession and a client? (3) What are the Central Practice Values of this profession? (4) What are the norms of Competence for this profession? (5) In what respects do the obligations of this profession take Priority over other morally relevant considerations affecting its members, and what sorts of Sacrifices do they require? (6) What is the Ideal Relationship between the members of this profession and Other Professionals and those who assist the profession? (7) What is the Ideal Relationship between the members of this profession and the Larger Community? (8) What ought the members of this profession do to make Access to the Profession’s Services available to all who need them? (9) What are the members of this profession obligated to do to preserve the Integrity of their commitment and to continue to grow in Professionalism?

NINE CATEGORIES OF PROFESSIONAL OBLIGATION

Now it is time to describe these nine categories of professional obligation more carefully. But it is worth explaining why they need to be carefully described—that is, how doing so can improve a dentist’s professional-ethical thinking.

Back in chapter 2

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