The Wrong Message and Why It Matters
After Dr. Bob Milford hires Dr. Sandra Ballman to join his office (see the case in chapter 10), the Ridgeview practice grows even faster. Milford is now deluged with requests from dental business consultants who wanted to meet with him and help him expand his practice in new ways. Meanwhile, the complaint Drs. Kamamata, O’Brien, and Della Galla sent to the Peer Review Committee of the local dental society had grown more complex, as several other area dentists joined the petition. Milford’s aesthetic marketing was drawing patients from their practices and, after their aesthetic work was done, many of the patients stayed to continue their general dentistry there.
Richard “Rich” Paulson, a dental business consultant, manages to get an appointment with Dr. Milford. Paulson’s marketing materials are carefully crafted to stress the enhancement of his clients’ dental professionalism and the commitment of their practices to patient-centered dentistry as he helps their practices continue to grow. This appeals to Dr. Milford. His interest in growing the practice is being driven, at this point, by the fact that he is spending all his time doing aesthetic work while Dr. Ballman is handling the general dentistry needs of their patients. Dr. Milford realizes he is missing the kinds of relationships with patients that were characteristic of his full general dentistry practice. He is rarely experiencing this anymore as he focuses almost exclusively on satisfying patients’ aesthetic goals. What he doesn’t know is that Paulson was known within the dental consultant community as Richard “I’ll Make You Rich” Paulson.
Mr. Paulson hears Dr. Milford out about his wanting to get back to doing general dentistry again, about probably hiring a third dentist, and about getting Dr. Ballman or a new dentist more training in aesthetic dentistry. Dr. Milford thinks this will be a way to reach his goal. Unfortunately, Dr. Milford’s office is too small for this. He is hoping Mr. Paulson can help him sort out the financial challenges related to building an addition or moving to a larger site, as well as the practical financial and professional challenges of interrupting the practice and patient care during such a transition. However, Mr. Paulson isn’t actually interested in these things. Mr. Paulson wants to sell Dr. Milford on Paulson’s ways to grow profits without making such major disruptions to Dr. Milford’s current practice, which is already a success. “You don’t need to do all that to grow this practice into an immensely more profitable operation,” says Mr. Paulson. “You’ve already laid the groundwork for that beautifully. You don’t want to interrupt what you have here. You want to build on it. And the best way to do that is to start offering Botox treatments along with the aesthetic work you already offer.
“The market for Botox is huge, and you’re already in the business of helping your patients look better and feel better about themselves. Botox just adds to that, and the profit margins on it are fantastic! You also won’t need to add an operatory or move to a larger building. The operatories you have here will be plenty. All you’ll need to do is hire a part-time person licensed to do Botox injections or make it worthwhile for your second dentist to get licensed. You’re already paying her for the work she does herself and giving her a bit more when she sends you a patient for cosmetic work. If she were trained in Botox, the profit margins are so large you could give her half and keep half for yourself, and she would still think it was great.
“Or, if you only bring in a part-time dentist because there’s too much general dentistry for her to do that and Botox too, then you’ll still get, say, half the profit margin and you don’t have to pay any benefits to boot. Either way it’s a win-win situation for you and your people. And you escape all the hassle and potential lost business of constructing a new building or moving somewhere else. Why would you want to do that again? I understand that you would like to be doing more general dentistry. You spent years perfecting those skills and you want to be using them. But you don’t need a construction project to do that. Say you get Dr. Ballman, like you were saying, trained to do aesthetic work too. Well, in the interim you would take a hit because if you pick up the slack in general dentistry while she’s doing that, you’d lose the profits from the aesthetic work you’re not doing. But if you add Botox to your practice first, then you would break even during her training time, and the big profits would start rolling in as soon as she’s back full-time. And, you two would be sharing general and aesthetic work, however you two want to work that out.
“Either way, trust me, Botox is the path you should take to grow this practice’s profits. It will only better your reputation for aesthetics, and that’s what is bringing in most of your patients. I’m here to help you make that happen.”
Dr. Milford has never considered this as a way to grow the practice. Should he buy into Mr. Paulson’s proposal or not?
It is not the case that there is something wrong with running a commercially successful practice; it is, instead, a necessary component of practicing dentistry in our society. But a fiscally successful practice is not the first goal of a dental practice if dentistry and dentists view themselves and want to be viewed and treated by others as professionals. So it is important for every dentist to be asking what kind of message he or she is sending to patients in the chair, to prospective patients in the community, and to the public at large. Is this a message that is first and foremost about professionalism, collaborative decision-making with patients, fully competent care for them, and the other characteristics of ethical dentistry? Or is it a message that mirrors the commercial marketplace’s ways of thinking, valuing, and relating? Dental journals, especially the throwaways, are full of notices that could easily be coming from Richard “I’ll Make You Rich” Paulson, and many dental meeting sessions have a similar focus.
So where is dentistry heading? Will it still be a profession in a few decades? Will the larger society not be able to see a difference between what happens in dentists’ offices and what happens in the commercial marketplace?
Where dentistry is heading in the United States will largely be determined by what kind of messages the larger US society receives about dentistry. As chapter 2 explained, it is the larger society that accords dentists their special professional authority—to make socially determining decisions and to have the last word—about matters of oral health and to be, for the most part, self-regulating. It does this for two reasons. First, the dental profession has been recognized as having expertise that enables its members to respond effectively to people’s oral health needs and to dependably secure for them the essential components of oral and general health, autonomy in the sense of control over their bodies, and other important values. Second, the profession and its members make and, with very few exceptions, are ordinarily observed to honor a commitment to make the well-being of those they serve their highest priority and the cornerstone of what counts as ethical conduct and professionalism in dental practice. These are the essential characteristics that our society attributes to dentistry as a profession and the characteristics that every dentist is expected to embody and continually grow in in order to be correctly described as a professional.
It is therefore reasonable to assume that, if dentists were no longer thought to have expertise in matters of oral health, if dentists were viewed as ineffective or not dependable in properly addressing people’s oral health needs, or if it was concluded that dentists could not be counted on to ordinarily make the well-being of their patients their first priority, then the larger society would understandably withdraw dentists’ social authority and status as professionals. It is worth asking, then, if dentists are sending any messages to the larger community that would indicate such things are happening. The Interim Gies Ethics Project Report, published in fall 2016 by the American College of Dentists (ACD), offered significant empirical evidence that dentistry in the United States may well be sending these negative messages to the larger community. This chapter will examine a number of activities that are fairly common in dental practices in the United States that can unfortunately be easily interpreted as sending just such a message, and (along with chapters 14 and 15) it will suggest ways in which the opposite message—that dental expertise and dental ethics and professionalism are alive and well among dentists in the United States—could be made more prominent.
It is important to stress that, if dentists in the United States are frequently sending the wrong message to the larger society (even if they don’t realize it), it will not be enough to simply “say” or advertise the correct message more frequently. It will not be enough to merely repeat the profession’s commitments and high ideals. What will need to happen, to emphasize the correct message, is for every aspect of dentistry in the United States—every dentist in every practice and every dental organization regardless of its particular focus—to concretely practice what they preach. But dentists’ and dental organizations’ ability to do that will depend on serious efforts on their part (every dentist in every practice and every dental organization) to learn or relearn in concrete detail what dentistry’s ethics calls them to do and to be (to which this book hopes to make a contribution) and to actively engage in the kind of continuing—which, to be realistic, means daily—process of self-assessment and self-formation in professionalism that will be described in chapter 15.
But, as the Interim Gies Ethics Project report stresses, self-formation in ethics and professionalism cannot be effectively accomplished in isolation; it requires support and collegial assistance not just from other dentists but with other dentists. Therefore, the process of making sure that dentistry is sending the right message to the larger community—about its expertise, its relationships to patients, the effectiveness of its responses to their needs, and its commitment to give priority to patients’ well-being—must include individual dentists’ participation in dental professional groups and organizations. It must also include these organizations engaging in their own self-assessment and professional self-formation as organizations. This last theme will be the topic of chapter 14.
But the task of this chapter is to look at some common kinds of activities by which dentists send messages to the larger society that appear to diminish dentists’ commitment to the dental profession’s ethical standards and that challenge the conviction that it possesses special expertise about oral health.
Many professions’ codes of ethics address the issue of conflicts of interest with the simple directive that they are to be avoided. But this is not a useful directive because almost every activity that a professional engages in involves interests that can conflict, and the only way to avoid them would be to have never become a professional at all. Every time a dentist—or any other health professional—cares for a patient, for example, he or she is at the same time expending time, attention, and energy that could also be expended on some personal interest of the dentist (or of some other person that the dentist cares about or is responsible for). He or she is also, directly or indirectly, earning a living. Working for an Interactive Relationship with the patient and trying to maximize dentistry’s ranked Central Practice Values for the patient does not invariably mean these will coincide with a dentist’s other goals in life or other things a dentist values. At the same time, however, and as explained in chapter 6, the ordinary primacy that the ethical dentist gives to the well-being of the patient does not automatically settle every situation in which the patient’s interests and the dentist’s other interests happen to be at odds. Properly dealing with conflicts of interest often requires, instead, careful comparative weighing of possible harms in the context of an ethically appropriate relationship between the dentist and the person the dentist is serving.
The ethical question about conflicts of interest in dental practice, then, is not simply whether they can be avoided, although some can be avoided without serious harm to the patient, as will be explained. Careful comparative weighing of possible harms to the patient is required because the dentist’s interests in the situation may have the potential to interfere with the dentist properly exercising his or her expert judgment about what is harmful/beneficial for the patient. This comparative weighing can be summarized in five questions, which will be explained below.
The conflict of interest situations in dental practice that are the most complex, and that will be the focus here, are those in which there is commercial benefit to the dentist from an arrangement with the patient that either is not directly beneficial to the patient’s General or Oral Health or does not involve the dentist’s specific expertise in oral health. Many dentists, for example, sell dental goods. These include oral health compounds like dentifrices, fluoride products, sonic or mechanical toothbrushes, and other oral devices. These are products that the patient can purchase outside of a dental office and without a prescription. That is, the patient’s access to such products is not dependent on the dentist’s expert professional judgment in the same way as is oral diagnosis and treatment. Similar to these are situations in which dentists are selling health care services not directly involving dental care. Examples of these would include weight loss programs, holistic medicine regimes, some smoking cessation programs, or any number of other services. (Some dentists sell cosmetic products not related to patients’ oral health—for example, Botox injections. Those situations will be discussed in the next section on aesthetic dentistry.)
These situations are ethically complex because, if the dentist’s expertise in oral health is not involved in offering the product (as in the case of a weight loss program, for example), then the dentist-patient relationship in this respect is a commercial relationship rather than a professional one. Or, when the product does have some connection with oral health (as in the case of dentifrices, sonic or mechanical toothbrushes, some smoking cessation programs) the patient cannot tell—unless the dentist specifically discusses it—whether or not the dentist is selling the products simply to make money and, therefore, whether the dentist-patient relationship in this respect is actually a commercial relationship rather than a professional one. For, if the relationship is simply a commercial one, then the patient has no reason to think that the dentist’s commitment to give primacy to the patient’s well-being is operative. The dentist can very reasonably be thought to be maximizing his or her bottom line and, therefore, to be indifferent to whether the product or service is actually going to benefit the patient by securing dentistry’s Central Practice Values for that patient.
In order to determine whether such conflict of interest situations are professionally and ethically acceptable, the dentist should ask—and honestly answer—the following five questions about each such situation:
- Is there any harm that might result from the dentist’s secondary interests, and, if so, how serious is that harm?
- How likely to occur is the harm identified in question 1?
- If the dentist chose not to act because of the conflict of interest, what benefits would be lost and what harms would occur and to whom?
- How likely to occur are the harms and benefits identified in question 3?
- Which course of action available to the dentist is most likely (taking account of the answers to questions 2 and 4) to yield the least harm or the greatest benefit (taking account of the answers to questions 1 and 3), given the professional nature of the dentist-patient relationship?
Before applying these five questions to dentists selling oral health products, for example, there is another conflict of interest situation that arises daily in every dental operatory and that was already mentioned above—namely, that dentists earn their living by caring for patients, and the more services they perform, the more money they earn. This situation is regularly managed ethically—though not always—but it will be useful to apply these five questions to it to illustrate how they work.
Question 1: We can certainly imagine a dentist being tempted to recommend treatments to a patient not because they are needed but because they are lucrative for the dentist. Many dental patients seriously suspect that this has happened to them, a topic that will be discussed in a later section of this chapter. This possibility means that the answer to question 1—about possible serious harm to patients—is surely yes.
Question 2: If every dentist lived by the commitment to practice according to dentistry’s professional standards and to give priority to patients’ well-being, the likelihood that a dentist’s interest in business success will interfere with a dentist’s professional judgment on behalf of his or her patient would be zero. Although there certainly are exceptions, the public still ranks dentists among the most trustworthy of occupations. Therefore, it is reasonable to propose that the answer to this question is that the likelihood of harm in this circumstance is typically low.
Question 3 and question 4: The risk of harm to patients from dentists’ commercial and other secondary interests is assumed to be low, and this is important. For the only alternative currently available would be to have no one practicing dentistry at all; the harms and lost benefits of that action, of course, would be very significant. In addition, they would be all but certain.
Question 5: The potential harms and lost benefits of having no dentists would be far greater than the harms inherent in our current system. In addition, the likelihood of harms from dentists failing to put secondary interests in proper perspective, for whatever reasons, has been judged to be low.
It is therefore reasonable—assuming that the proposed answer to question 2 is correct—for the larger community to continue to support dentists’ authorization as the profession charged with caring for our society’s oral health needs; this is in spite of the fact that earning a living is, and will likely remain, an important secondary interest for dentists in our society. (Patients’ suspicions that this assumption is not accurate will be examined in a subsequent section of this chapter titled “Dental Expertise, Differing Diagnoses, and Overtreatment.”) When a dentist is selling oral health products, however, the ethical character of this particular relationship becomes much more ambiguous.
Question 1: Should the patient assume that the dentist is as committed to the patient’s health in this relationship as the dentist is to matters of professional diagnosis and treatment? Or should the patient just know that this is now a commercial relationship to be managed by the “let the buyer beware” principle? Without further information, the patient really cannot tell. That is, because of its apparently commercial character, harm to the patient is possible, and the probability of this harm needs to be considered.
Question 2: The patient needs more information in order to make a dependable judgment of the role of the dentist’s secondary interests in the transaction. In other words, absent more information about the dentist’s true reasons for selling the product, the risk of harm could well be significant.
Question 3 and question 4: Because of this lack of information, some patients would prefer to separate the commercial and professional relationships; that is, they lose less by buying the products at an ordinary commercial establishment where they know the rules of the game.
Question 5: Such patients would, in effect, be saying that the advantages of separating the commercial and professional relationships are less risky than combining them in the same setting. In the language used earlier, they are saying it is likely that there is more benefit in forgoing this particular relationship with the dentist than in dealing with its potential harms.
Many dentists who sell such products seem to be aware of the ethical ambiguity of these commercial transactions. They may work to ease the ambiguity by explaining to patients that they sell such products simply as a convenience to their patients, to save them a trip, or to assure them that the product they are purchasing is exactly the right one. But such explanations, however reasonable, don’t address the ethical ambiguity of the situation. What would be needed to address it carefully would be the equivalent of the disclosure statement like those offered by speakers at dental conferences in which their conflicting interests are identified.
That is, to lessen the patient’s uncertainty about the likelihood that the dentist’s special secondary interests might be interfering with his or her professional judgment on behalf of the patient, the dentist would need to provide details about those secondary interests. The dentist would need to say, and of course to say honestly, that he or she is not profiting at all from the sale of this product and is providing it at cost (though “at cost” can legitimately include some charge for handling, storage, billing, etc.). Or if there is a markup on the cost of the product, then the dentist needs to say that—like the drug store on the corner—his office adds a 30 percent markup above cost, or whatever it is. Of course, some dentists who are making a few dollars by charging the usual markup might be embarrassed to disclose that so frankly to their patients. But if so, it would be valuable for them to ask themselves why they would be embarrassed. Is it because they are admitting that they have set aside the professional components of their relationship with the patient for the sake of a few dollars?
In any case, the weighing of benefits and harms according to the five questions must be done in the context of the requirements of the professional relationship between dentist and patient. One thing that requirement implies is that protecting the dentist’s privacy (about details of the sale, etc.) is not valuable enough to outweigh the value to the patient of making well-informed judgments about commercial products that the dentist recommends. For, because of the ethical ambiguities just discussed, the patient’s judgment can hardly be well informed without such disclosure.
For the dentist’s part, of course, the answer to question 5 might be that, rather than having to make such disclosures to patients, the best way to avoid such ethical ambiguities is to refrain from selling products at a markup. Since the patient can buy the same product elsewhere (our example has been assuming this is the case), the harm to the patient of not being able to buy the product from the dentist is ordinarily very small.
This same reasoning applies to situations in which dentists are selling health care services not directly involving dental care. The dentist needs to be asking the five questions carefully and should be able to see that, since nothing in recommending these products depends on the dentist’s expertise as a professional, the relationship to the patient in such situations is almost certainly only commercial. But that means that the risk of the dentist’s secondary interests interfering with his or her judgments, about what will harm or benefit the patient, is even greater than in the case of selling oral health products. In fact, there is good reason for the patient—and the dentist—to wonder why the dentist believes he or she has any business recommending such products when they are so far removed from the dentist’s expertise in oral health.
The importance of these ethical concerns is heightened whenever the dentist explicitly recommends the product or service without having personally studied the evidence supporting its effectiveness. Such recommendations are ethically problematic even if, when the dentist has previously recommended the product or service to patients, they have not been harmed or have not complained. Dental expertise requires that a standard of evidence considerably higher than this be employed in a dentist’s explicit recommendations. Moreover, even if the dentist does not explicitly recommend the product or service, the fact that the dentist offers it to the patient for purchase may appear to be an expert recommendation in the eyes of the patient. Thus, not saying anything but merely offering the product or service may well be misleading. If the dentist does not have sufficient evidence to recommend it on the basis of his or her actual professional expertise, the dentist should explain this to the patient in order to avoid misleading him or her in this way. (Obviously, the simplest way to avoid the ethical challenges of these situations is again to refrain from offering products or services in the first place, especially those not directly connected to patients’ Oral Health. In other words, asking the third of the five questions seriously is a necessary first step in practicing dentistry ethically.)
It is also important to mention, in connection with using the five questions to ethically assess conflicts of interest situations, that there is strong empirical evidence supporting the position that, no matter how impartial we may think we are able to be, when our own personal interests are part of a transaction, we will tend to overvalue them in comparison with the interests of other parties. At the very minimum, when we ask the five questions about a conflict of interest situation, we should assume that, on close calls, we are underestimating the risk of benefits to ourselves interfering with our ability to make dependable expert judgments about the well-being of other parties.
In addition to the subtlety of the ethical judgments that conflict of interest situations call for, and the need to avoid bias in favor of ourselves in such situations, it is important to ask what kind of message a dentist sends when what happens in the operatory moves beyond professionally guided dentist-patient interactions to include commercial transactions. For many patients, the professional-patient relationship still has a special character that is very different from a commercial relationship, and this is the message that dentistry as a profession has long proclaimed. But if the two relationships are mixed together in practice, and especially if the patient is left uncertain about whether the dentist is aware that they are different, the message to the patient—and to those with whom the patient interacts afterward—can very well be that dentist-patient relationships are in the process of changing from professional to commercial. That message does not bode well for the future of dentistry as a profession.
As chapter 5