Transcript The Terrain of Ethics

Ethics . . .
in the
Profession of Dentistry
Rocky Mountain
Dental Convention
Denver, Colorado
Janurary 24, 2014
Rodin’s
The Thinker
• The Thinker, created by Auguste Rodin, noted
French sculptor (1840-1917), is considered one of
the world’s great sculptures
• The Thinker was the capstone piece of a very large
unfinished sculpture of Rodin, The Gates of Hell.
• The Thinker provides an appropriate visual
metaphor for our “thinking” about professional
ethics.. We will think together about the importance
and relevance of ethics as to the profession of
dentistry.
“If you wish to converse
with me, [first] define your
terms.”
Francois Marie Arouet
“Voltaire”
DEFINING
PROFESSION
“What Does It Mean To Be A
Member Of A Profession…
A Professional?”
Professional as…
“Not An Amateur”
contrasted with
The Classical
‘Learned’
Professions
Learned’ Professions As
Conceptualized
Historically
• Law
• Medicine. including dentistry
as a specialty of medicine
• Clergy
“Knowledge Is Power”
Baruch Spinoza
Dutch philosopher
• The concept of profession
developed from the
extraordinary power these
groups of individuals had over
those they served.
• They were the only literate
members of the society.
– Law: Power over Property
– Medicine: Power over Person
– Clergy: Power over Providence
• Classically and historically,
professionals ‘profess’ (promise,
avow) a technical competency based
on a tradition of advanced
learning/education for which they
will be morally accountable in
placing this expertise at the service
of society.
• The concept of profession is deeply
rooted in the notion if “making a
promise” to another. The promise
that I will always use my knowledge
to do what is in your best interest.
• Therefore the quintessential quality
of the professional relationship is:
TRUST
Professional Relationship
is Fiduciary
• To be a fiduciary means to stand
is a special relationship of trust,
confidence or responsibility to
another.
• Professionals are in a fiduciary
relationship due to the power
they hold over others; power
based in knowledge. They
“know” when others do not.
• Therefore, others must trust
professionals to use the
knowledge they have in
patient’s/ client’s best interest.
The Nature of the
Professional
Relationship
• Metaphors are figures of speech in
which we use a word or expression
that is typically used to designate
one thing is used to designate
another, thus making an implicit
comparison; suggestion one idea as
analogous to another. “All the
world’s a stage.”
• The word ‘covenant’ metaphorically
helps further elucidate the nature of
the relationship between
professionals and society
The Covenant of the
Physician [Dentist]
by William F. May
In its ancient and
most influential form a
‘covenant’ included...
• A pledge or promise
• An exchange of gifts
• A change of being
Marriage...A
Contemporary
Covenant
• Pledge or promise: the vows
• Exchange of Gifts: the rings
• Change of Being: husband/wife
Dentistry as Covenant...
• Pledge or Promise:
– Society promises dentistry a
monopoly to practice.
– Dentistry promises to serve
society faithfully and well.
• Exchange of Gifts:
– Society gives dentists a statesupported and heavily subsidized
education, low interest loans, and
the privilege of self-regulation.
– Dentistry gives society its
knowledge, skills, and talents.
Change of Being
• Ordinary individuals become
‘dentists.’
• Other individuals become
‘patients.’
• Without ‘patients’ dentists
could not be ‘dentists.’
• Without ‘dentists’ patients could
not be ‘patients’ and the the
beneficiaries of oral health.
Covenant Reaffirmed
• On an individual basis each
time two individuals meet in
which one agrees to be the
dentist or healer, and the other
agrees to be the patient...to be
healed.
• The duty of “doing good” for
the patient’s oral health is
rooted in the prior covenant of
the profession with society, as a
profession.
Reciprocity
• The patient gives self to the
dentist in order to be the
beneficiary of oral health.
• The dentist gives self to the
patient in order to gain the
fulfillment of service and
receive a fee from which to
support self and family.
Conceit of
Philanthropy
• Health professionals (dentists)
consistently proclaim their
service to mankind.
• This idea of service succumbs
to the “conceit of philanthropy”
when the professionals
relationship to patients is
assumed to be
gratuitous…rather than
reciprocal; is condescending.
• There is mutuality/reciprocity in
the relationship flowing out of
the “covenant.”
The Concept of
Profession is a Cultural
Construct
“Culture is the collective,
mutually shaping patterns of
norms, values, assumptions,
beliefs, standards, and attitudes
that guide the behavior of
individuals and groups, whether
those groups be families,
religions, races, geographic
regions, nations, businesses, or
professions.
• Norms-what the culture understands
as normal; that which should occur
naturally; the culture’s guiding rules
or principles.
• Values-what the culture desires;
desires create purpose- purpose
provides meaning.
• Assumptions-what the culture takes
for granted; what it presupposes,
takes for granted.
• Beliefs-that in which the culture
places its trust and confidence.
• Standards-the uniform referents of
the culture; the touchstones used in
measuring and evaluating.
• Attitudes-the emotional intentions of
the culture; what it feels and wills.
Culture and Ethics
• To describe differences between
cultures is not necessarily to
draw moral conclusions; only
to characterize differences.
• Of course, one can prefer the
characteristics of one culture
over another. Preferences are
not (necessarily) morality.
• French/Chinese
Socialism/Capitalism
African/European
Muslims/Jews
Profession/Business
The Culture of
Dentistry As A
Profession
• Norm - Oral health is a primary
good; an end in itself.
• Value - Care and concern for all
people and their oral health.
• Assumption - Societal good
• Belief - Cooperation and reciprocity
with society can result good for all.
• Standard - Justice/Fairness
• Attitude - Egalitarianism
“Professions are organs contrived for
the achievement of social ends
rather than as bodies formed to
stand together for the assertion of
rights or the protection of interests
and privileges of their members.”
“The organizational component of
the profession is explicitly meant to
emphasize the advancement of
common social interests through the
professional association.”
Abraham Flexner
U.S. Educator and
Reformer of Medical Education
1915
“The core criterion of a full
fledged profession is that it must
have means of ensuring that its
competencies are put to socially
responsible uses …
professionals are not capitalists,
and they are certainly not
independent proprietors or
members of proprietary
groups.”
Talcott Parsons, professor
Harvard University
“Dean” of American Sociology
The Culture of
Dentistry As A Business
• Norm - Oral health as a means
• Value - Entrepreneurial;
building a successful enterprise;
profits
• Assumption - Private good to be
maximized
• Belief - Dentistry as a part of
the free enterprise system
• Standard - Marketplace
• Attitude - Social Darwinism
Tension Between
Dentistry as a Profession and
Dentistry as a Business
• Dentistry has historically understood itself to be a
profession (and continues to do so), and has laid
claim to professional privileges. It has been
understood to be focused primarily on serving the
oral health needs of patients, with the financial gain
derived from such being of a secondary nature;
cooperating with patients for the patient’s best
interest.
• Yet, many (most?) dentists today understand
themselves to be practicing in the marketplace of
health care, competing for patients to provide for
the legitimate expenses of conducting a practice;
caring for patients with the primary motivation of
earning a significant profit for their services—
operating a business.
• There is difference (a tension) between the
traditional understanding of the culture of
profession and the culture of business.
“A new language has infected
the culture of . . . health care. It
is the language of the
marketplace, of the tradesman,
and of the cost accountant. It is
a language that depersonalizes
both patients and health
professionals and treats health
care as just another commodity.
It is a language that is
dangerous.”
Rashi Fein, professor
Health Economics
Harvard University
Socrates in Dialogue with
Thrasymachus
“But tell me, your physician in the
precise sense of whom you were just
speaking, is he a moneymaker, an
earner of fees or a healer of the
sick? And remember to speak of the
physician who really is such...“
"Can we deny then, said I, that
neither does any physician, insofar
as he is a physician, seek to enjoin
the advantage of the physician but
that of the patient."
Plato
The Republic, 341 B.C.E.
Distinction Between
Social Goods and
Consumable Goods
An Inquiry Into The Nature and
Cause of the Wealth of Nations
Adam Smith
1776
Argued that there are basic social
goods upon which the “free market”
for consumable goods is dependent,
and that these social goods should
not be considered a part of the
“market economy.”
Dentistry?
• Is dental care a social good
similar in nature to police
protection, fire protection,,
and basic health care?
public education, public
safety?
Or
• Is dental care a consumable
good similar in nature to
purchasing furniture,
electronics, vacations,
travel, sporting equipment
or entertainment?
Categorical Imperative
“Act so that you treat humanity,
whether in your own person or
that of another, always as an
end and never simply as a
means.”
Immanuel Kant
German Philosopher
1724-1804
Patients: Means or Ends?
• As a profession, dentists serve the end of the
well-being of their patients.
• To place one’s own interest above the welfare
of a patient is to treat a patient as means to
the dentist’s ends. The patient becomes an
‘object’ to be used by the dentist in achieving
personal goals. This is reification; treating
another as an object--dehumaning.
• “Always treat others as ends in themselves,
never as a means to one’s own ends.”
Immanuel Kant’s Moral Imperative.
• Clearly we derive financial gain from our
life’s work, but it is derivative; a by-product
of us fulfilling our promise to our patients as
professionals that they can always trust us to
do what is in their best interest.
Patients: Means or Ends
• Dentistry as a business sees the oral
health of patients, not as ends in
themselves, but merely means to the
dentist’s personal ends.
• Dentistry as a business serves the
end of personal profit for the dentist.
• Understanding dentistry primarily as
a business places dentistry in the
marketplace where oral health care
becomes a commodity produced and
sold for a profit.
• The business of selling cures
undermines the classical professional
model—a model rooted in a tradition
of caring.
“Health care is not a commodity,
and treating as such is
deleterious to the ethics of
patient care. Health is a human
good that a good society has an
obligation to protect from the
market ethos.”
Edmund Pellegrino, M.D.
Distinguished Bioethicist
Georgetown University
Factors Collapsing Distinction
Between Dentistry as a Profession
and Dentistry as a Business
• Power differential going away.
(Education of the populace, Internet)
• A considerable dimension of dental practice today is
elective, that is for improved of esthetics, and not
healthcare in the sense of treating disease.
• Increasingly traditional professionals are working in
corporate/business settings. In the U.S. 60% of all
physicians work for corporations—with a profit
motive.
• Business has adopted traditional professional
standards of putting the client/customer good first.
The former warning of the marketplace, “caveat
emptor” (“let the buyer beware”) is no longer
applicable, due to customer guarantees.
• One American bioethicist, William May, has
suggested that individuals today stand a better
chance of receiving fair dealing in the marketplace of
business than they do in the offices of the
professions.
A Lingering Question
• Is a visit to the dentist for care
substantively different than a visit
to the Porsche dealership to buy a
new car, or to the grocery store to
purchase food, or to the
department store to purchase a new
suit or dress?
• If so, how so? Does a distinction, or
lack of a distinction, result in
understanding dentistry more as a
profession or as a business?
Charles O. Wilson
and
Enlightened Self-Interest
• Charles O. Wilson was the CEO of
General Motors at the apogee of GM’s
success in the 1950s.
• While testifying before a Senate
Committee he made a statement that was
subsequently widely misquoted as, “What
is good for General Motors is good for the
Country.”
• In actuality, he said the opposite, “What is
good for the Country is good for General
Motors.”
• Today, what is good for the oral health of
the American people is good for the
profession of Dentistry.
• However, we must be careful not to believe
the opposite, that what is good for
Dentistry is good for the American people.
Defining Profession
Summarized
• Professions emerged in the Middle Ages in
Europe with the increasing knowledge, and
therefore power, of the clergy, attorneys,
and physicians.
• Professions “profess” (promise) to place
themselves in a fiduciary relationship with
their constituency. Thus TRUST is the
quintessential quality of the professional
relationship.
• Professions have traditionally been
culturally distinct from businesses.
• Forces are work in the environment that
are challenging the validity of the concept
of profession.
• Yet, their seems to be an inherent
difference in the transactional relationship
between dentists/physicians and their
patients, and automobile salesmen and
their customers.
Defining Ethics
ETHICS is a branch of the
intellectual and academic discipline
of PHILOSOPHY.
PHILOSOPHY literally means:
“Love of Wisdom”
•
•
•
•
•
•
Pondering . . .
Wondering …
Reflecting …
Questioning …
Reasoning …
Speculating ...
About
Life
“Philosophy is everybody’s
business. The human being is
endowed with the proclivity to
philosophize.”
Mortimer Adler
20th Century philosopher
ETHICS is the branch of the discipline
of philosophy that studies morality. It
is the “science” of the moral. It
attempts to answer the questions of
“What should I do?” or “How should I
behave?”
MORALITY is that domain of
understanding that relates us to our
world, and to other humans in our
world. Moral behaviors are those
actions that can be evaluated as good or
right using reasoned, objective criteria.
*The distinction is between the object
of study (morality) and the study itself
(ethics).
Ethics Is Reflection On
the Ultimate Good ... the
“Summun Bonum”
•
•
•
•
•
•
•
Good and Badness
Rightness and Wrongness
Virtue and Vice
Approval and Disapproval
Oughts and Ought Nots
Ends and Means
Judgments of Value and
Judgments of Obligation
• Goals of Living and Methods of
Achieving Those Goals.
Ethics Raises
Questions of Values
• What is important?
• What matters?
• What endures?
• What is meaningful?
• What is worthwhile?
• What is good?
• What is right?
“We are all moralists
perpetually, geometers (or
dentists) only by chance.”
Samuel Johnson
English lexiographer
1709-1784
Drawing Distinctions
Among . . .
• Ethics
• Law
• Religion
Law
• Law is the societal institution of binding rules Of
conduct, with enforcement by the policing authority of
government
• Law is public consensus and not infrequently a
temporary one.
• Law is predicated on the concept of justice, with the
scales of justice being the symbol of law.
• Justice is the foundational principle of all of Ethics.
Law
• However, law is the floor, not the
ceiling for human conduct.
• Ethics is higher than the law, but not
above the law.
• It is ethical (moral) to obey the law,
as it is a society’s best judgment of
what is just or fair. However,
consider that civil disobedience can
be a moral protest against unjust
laws.
• Plato’s attempt to describe the
characteristics of a truly just
(and good) society.
Religion
• Literally, religion means a
reconnecting or reuniting; binding
together. From the Latin “re”—
again, and “ligare”– to connect.
• Religion is a means of overcoming
the estrangement or separation man
feels from God, or in naturalistic
religions, Nature.
“Is conduct right
because the gods
command it, or do the
gods command it
because it is right?”
Socrates
Plato’s Euthyphro
Thomas Aquinas, the great theologian of
the Middle Ages, analyzed the question:
1. God commands us to do what is right,
then:
a) The actions are right because God
commands them, or
b) God commands them because they are
right.
2. If a) then, from moral perspective, God’s
commands are arbitrary and the doctrine of
goodness of God meaningless.
3. If b) then, admit standard of right and
wrong independent of God.
4. From religious point of view, undesirable
to regard God’s commands as arbitrary, or
to give up in goodness of God.
5. THEREFORE, even from religious
perspective, a standard of right and wrong
independent of God must be accepted.
Theory of Natural Moral Law
Thomas Aquinas
1225-1274 C.E.
• While various religions may teach and
emphasize moral concepts, it must be
emphasized that morality is inherent in the
very nature of man.
• Adherence to the precepts of morality is
incumbent on humans regardless of the
presence or absence of any religious
commitment.
HIERARCHY OF ETHICAL VIEWS
INDIVIDUAL
FAMILY
CULTURE
NATIONALITY
RELIGION
HOMO SAPIENS
Two Major
Questions of Ethics
• What is the good life?
that is
What should I value?
“ETHICS OF ASPIRATION”
……………
• What is right?
that is
What duty do I have to others?
“ETHICS OF OBLIGATION”
ETHICS OF
ASPIRATION
“What is the nature of the
‘good life’?”
ETHICS OF
OBLIGATION
“What duties does one owe to
one’s fellow human beings . . .
in order to live in a civil
society?”
• “Man is by nature a political
animal.” (Aristotle)
• Aristotle’s term “political “ is
the synonymous with our usage
of the word ”social.”
• We are not hermits. By nature
we live in groups, cooperating
with one another to survive.
• We are social animals/beings.
• Morality, that discipline that
relates us to our world and other
individuals in our world,
evolved when our early hominid
ancestors came to understand
that ‘rules’ were necessary for
social living.
• Rules of cooperation among the
species were imperatives for
survival in a hostile world.
Moral Sense
• Biological evolution has created in us
homo sapiens the capacity for empathy, a
sense of fairness, and a capacity for
conflict resolution—the essential requisites
for developing a moral system.
• Francis Hutcheson and David Hume,
English philosophers, writing before
Darwin, understood humans to have a
“moral sense” that was innate.
• Contemporary primatologists have
confirmed that our primate relatives also
demonstrate a the capacity for empathy, a
sense of fairness, and capacity for conflict
resolution.
What if there were …
–
–
–
–
–
no rules of morality?
no laws?
no police?
no courts?
no government?
LEVIATHAN*
Thomas Hobbes
1651
*A literally a large sea monster
mentioned in the Book of Job,
where it is associated with the
forces of chaos and evil. For
Hobbes it was government.
“The State of Nature”
(Hobbes)
1. Equality of Need
2. Scarcity
3. Essential Equality of Human Power
4. Self-Interest
Resultant:
A Constant State of War, of One
with All...”
Where:
“Life is Solitary, Poor, Nasty,
Brutish, and Short.”
Cooperation Is
Essential...
. . . to escape the “state of
nature” and to live, in an
ordered society (safe,
stable, predictable) where
we each can pursue the
realization of our potential;
our life’s goals.
Moral Rules Are the
Basis for Cooperation
Moral Rules
--Examples -•
•
•
•
•
•
•
•
•
•
Don’t Cheat
Don’t Cause Pain
Don’t Disable
Don’t Deceive
Don’t Deprive of Freedom or Opportunity
Don’t Deprive of Pleasure
Don’t Kill
Don’t Break Your Promises
Don’t Break the Law (Obey the Law)
Don’t Fail to Do Your Duty (Do Your Duty)
Summarized:
Don’t Cause Others Evil or Harm
Moral Rules are rules or
principles that no rational
person would want violated
with regard to themselves or
anyone for whom they cared
… without reason. They are
rules that protect the
individual from suffering or
evil at the hands of another.
Obligations
of the Social Contract
• Our duty, to gain the benefits of an ordered
society, requires that we set aside our short
term self-interested inclinations in favor of
general rules that impartially promote the
welfare of everyone … including ourselves
(ultimately); rules that are in our
enlightened self-interest.
• We can do this because others in society
have agreed to do the same thing, because
it is in their enlightened (ultimate) selfinterest as well.
• The social contract is how we escape the
“state of nature” and create an ordered
society, escaping anarchy.
“The law of nature…which
obliges everyone, and reason
which is law, teaches all
mankind who will but consult
it, that being all equal and
independent, no one ought to
harm another in his life,
health, liberty of possessions.”
John Locke
English philosopher
1632-1704
Moral Rules Are
Universal, Not Absolute
• Universality in applying the
moral rules means that all
rational human beings with
voluntary abilities are to
abide by the moral rules.
• Moral absolutism is the
claim that we ought never
break any moral rule for any
reason.
Moral Justification
Example:
Nazi storm troopers at the door of
the Dutch business where Anne
Frank and her family are hiding-does one lie to the storm troopers,
and violate the moral precept, "do
not deceive," or tell the truth,
revealing the hiding place of the
Frank family, and violate the moral
rule, "do not deprive of freedom or
opportunity?" The moral life is
ambiguous, and frequently requires
reflection and justification.
Ethics
as a
‘Blunt Instrument’
• Ethics is a fairly ‘blunt instrument,’
it is not a ‘scalpel’ that cuts sharply.
• Although precise and rigorous,
ethics does not enable one to
determine that one and only one
action is moral.
• Certain alternatives may be ruled
out, but not infrequently range of
possible actions often remain that are
morally acceptable.
Ethics
as a
‘Blunt Instrument’
(continued)
• Sometimes all possible actions
infringe on one moral rule or
another.
• It sometimes becomes a matter
of determining which is the
lesser of two evils, or
• which moral rule deserves
receiving the most weight in a
particular circumstance.
Moral Justification
• Everyone is always to obey the
rules except when impartial, rational
people can advocate that violating it
be allowed.
•On reflection, the consequences of
following a moral rule in a situation
could result in more harm than good.
•And, as has been indicated, not
infrequently, all of the options
available in a situation would result
in violating a moral rule.
•Thus reflection forces consideration
(and justification) of which course
of action will result in the greater
good or the lesser harm.
Applying Moral
Justification
• “Moral Justification” suggests
that when impartial, rational
people agree on the resolution
of a particular moral issue when
applying the moral rules, then
such is morally permissible.
• When they cannot agree, the
limits of acceptable behavior
are determined by what
impartial, rational people can
accept.
Kant’s “Categorical
Imperative”
• Immanuel Kant, the 19th century German
philosopher, helps further characterize moral
justification with his famous dictum,
The Categorical Imperative: “act only on that
maxim that you would will it as a universal law.”
• If your action in a given circumstance could be
willed to be universalized, that is, you would
advocate that all people do what you are proposing
to do in like circumstances, then you could make
the claim that you decision is impartial and
appropriate.
Moral Rules
(Duties to Others)
Correspond to
Individual Rights
I have right
to:
Therefore …
You have
duty to:
Honesty
…
Not Deceive
Fairness
…
Not Cheat
Freedom
…
Not Restrict
Life
…
Not Kill
Possessions
…
Not Steal
Why Cooperate and
Keep the Moral Rules?
Self-Interest
• If we do not live by the moral
rules, treating others fairly or
justly, we cannot expect to gain
the benefits of living in a
ordered society. If we make a
habit of doing harm or evil to
others, people will not be
reluctant to do harm or evil to
us.
• This acknowledgment of the
value to ourselves of abiding by
the social contract with its
notion of moral rules is
traditionally referred to as
“enlightened self-interest.”
Concept of Justice
“… When a number of
persons engage in a mutually
advantageous cooperative
venture according to rules,
and thus restrict their liberty
in ways necessary to yield
advantages for all, those who
have submitted to these rules
have a right to similar
acquiescence on the part of
those who have benefited from
their submission.”
A Theory of Justice
John Rawls
Reciprocity
“Is there a single word such that one could practice
it throughout life?” Confucius replied,
“Reciprocity…do not inflict on others what you
yourself would not wish done to you.”
Confucius
China
Sixth Century, B.C.E.
The Golden Rule
Plato
Classical Paganism
“ May I do to others as I would
that they should do to me.”
Plato
Fourth Century, B.C.E
Jesus of Nazareth
Christianity
“Whatsoever ye would that men should
do to you, do ye even so to them”
Jesus of Nazareth
First Century, Common Era (C.E.)
But…
What Is the Role of “Doing
Good” in the Moral Life?
The Moral Ideals
“Prevent Evil or Harm”
Beach Scenario
David playing in the surf …
“do not kill”
David picking up sea shells …
“no rule of morality violated”
“prevented harm”
David on the lifeguard stand
“failed to do his duty”
Defining Ethics
Summarized
• Ethics is about how to live.
• Ethics concerns itself with how one should
relate to others—the obligations one incurs
from living in society. However, it also
concerns itself with the good life—that to
which one should aspire.
• Ethics, at its foundation, is about rules of
cooperation.
• Ethics, as cooperation, focus on the idea of
reciprocity, frequently designated the
Golden Rule: “ May I do to others as I would
that they should do to me.”
• Ethics has evolved as a result of the evolution
of a moral sense in homo sapiens.
• Ethics is related to both law and religion, but
is more basic than either, and to be
distinguished from both.
• Ethics is ultimately about justice, that is
fairness in the social contract. The concept of
fair treatment of others, and by others,
including society, is key to understanding
ethics.
Professional Ethics…
• is based in the moral rule, “do
you duty.”
• Ethics in dentistry derives from
the role dentists assume in
agreeing to enter into
relationships with society
generally, and other humans
individually, to ‘do good’ for
them with regard to their oral
health.
• Primary to the concept of
profession is benefiting society. The
moral duty of the dental profession is
doing good for the oral health of our
patients and society.
• The moral rule of not causing harm
becomes the moral ideal of
preventing evil or harm by the
positively promoting the good of
patients in dentistry’s avowed
expertise…oral health.
•Professional ethics in dentistry flows
from the moral rule to “do your
duty.”
Justice
In explicating the moral duties
of the profession of dentistry to
society generally, and to
individual patients specifically,
we must return to the
foundational concept of ethics,
that is, justice or fairness in
relationships.
A Theory of Justice
• Rawls understands justice to exist in two senses:
– Justice in inter-personal relationships.
– Distributive Justice, how are the benefits and
burdens of society to be fairly distributed?; or
what is generally understood and referred to as
Social Justice; and
• In both senses, Rawls is concerned with justice as
fairness.
Justice/Fairness
in Dentistry
• Exploring ethics in dentistry
forces two major questions:
– What constitutes justice/fairness
in the relationship of individual
dentists in their clinical
encounters with patients?
– What constitutes justice/fairness
in the relationship the profession
of dentistry with society at large?
Justice or Fairness
in the
Individual Dentist/Patient
Encounter
Two Moral Principles
Establish
Context for the
Dentist-Patient
Relationship
• Principle of Beneficience
Do good for the patient by promoting
their well-being…their oral health.
• Principle of Respect for Autonomy
Each person should be self-determining
. . . the author of his or her own life.
Beneficence
• The goal of the relationship in
which one assumes the role of
health care practitioner/dentist
and the other patient is the
benefiting of the patient.
• This benefiting is
accomplished by the dentist
providing the highest quality of
care possible contingent on the
profession’s current scientific
understanding, the clinical
circumstances, and the patient’s
desires.
Hippocratic Oath
“I will use treatment to
help the sick according to
my ability and judgment,
but I will never use it to
injure or wrong them.”
ADA Principles of Ethics
and Code of Professional
Conduct
“The dentist’s primary professional
obligation shall be service to the
public. The competent and timely
delivery of quality care within the
bounds of the clinical circumstance
being given to the needs and desires
of the patient, shall be the most
important aspect of this obligation.”
Principle One:
Service to the Public and Quality
Care
Continuum of Beneficence
Promote Good
Prevent Evil or Harm
Remove Evil or Harm
Do Not Cause Evil or Harm
(Non-maleficence)
Who Decides About
Goods and Harms-- Risks
and Benefits?
•
•
•
In providing goods or benefits,
clinicians in dentistry acknowledge
there are inherent risks of harms.
Philosophically, the professional
fee is understood as a “harm” the
patient must incur.
Dentists have the duty to weigh
benefits against possible harms,
and minimize the risk of harms.
But the dentist’s conception of
benefits and risks may be different
from the patient’s.
Whose values should prevail?
Respect for Autonomy
• Autonomy derives from the
Greek and literally means selfrule, self-governance... being
one’s own person; the author or
architect of one’s life.
• The moral rule, “do not
deprive of freedom or
opportunity,” means it is moral
or right to grant self-governance
to others.
Informed Consent
• Adequate information, with
adequate understanding
• Lack of coercion
• Competence
Adequate Information
with
Adequate Understanding
• The concept of adequate
information/understanding can
deteriorate into a mechanical
rehearsal of data to legally protect
the dentist unless tempered with the
idea of patient comprehension. This
is done by processing information
reciprocally; asking for patient
understanding and validation of the
information.
• Adequate information/understanding
does not require that the patient be
told everything there is to know, but
only the information adequate to
make an ‘informed decision;’
information that a reasonable person
would want to have.
Adequate Information
• Nature of the Problem
(Diagnosis)
• Goals of Treatment
• Alternatives in Treatment
• Advantages/Disadvantages
• Benefits/Risks
• Recommended Treatment
• Prognosis
• Cost
Legal Standard for
Adequacy of Information
Reasonable Person Standard
Disclose the benefits and risks that a
reasonable person, in what the
practitioner knows to be the patient’s
position, would be likely to deem
relevant in deciding whether to
accept or forego a proposed therapy.
Accepted by the courts on the
grounds that: “the scope of the
standard is not subjective as to the
practitioner of the patient; it remains
objective with due regard for the
patient’s informational needs and
with suitable leeway for the
practitioner's situation.”
Lack of Coercion
Modifying Behavior
Education
Persuasion
Manipulation
Psychological Coercion
Physical Coercion
Competence
• Patients must possess cognitive
decision making capacity in
order to be able to provide an
informed consent.
• Decisional capacity requires:
– Possession of a set of values and
goals.
– Ability to communicate and
understand information, and
– Ability to reason and deliberate
about one’s choices.
Competence
Groups of individuals
unable to reasonably
deliberate (rationally
consider) on treatment
options and provide an
informed consent are:
– minors
– extremely anxious patients
– mentally ill
– mentally retarded
– patients with dementia
Informed Consent
• Must be emphasized that
informed consent is primarily a
concept of ethics, and only
secondarily a doctrine of law.
• With an valid informed consent,
a dentist can provide most any
treatment for a patient.
• Absent a valid consent, a dentist
should not provide ANY
treatment for a patient.
Informed Consent
Logistics
• A signed treatment plan is not
necessarily an informed
consent.
• A form with a signature at the
bottom is not necessarily an
informed consent.
• A signed so-called “general
consent” form is not an
informed consent.
• Informed consent does have to
be documented.
Veracity
(Truthfulness)
• Some argue that the obligation of
veracity derives from the principle
of respect for autonomy.
• Certainly a valid consent to
treatment must be based on
information provided that is truthful.
• If the relationship between the
dentist and patient is, in fact,
fiduciary, one based in trust, such a
fiduciary (trusting) relationship
cannot be established and maintained
absent truthfulness.
Legal Opinion:
Informed Consent
John Canterbury
Versus
William Spence
(1972)
“Every human being of adult years
and sound mind has a right to
determine what shall be done with
his body…True consent o what
happens to one’s self is the
informed exercise of a choice, and
that entails the opportunity to
evaluate knowledgeably the options
available, and the risks attendant
on each.”
Quality
as an
Issue of Ethics
Quality Defined:
“The degree to which health
services for individuals and
populations increase the likelihood
of desired health outcomes and are
consistent with current
professional knowledge.”
Institute of Medicine
National Academy of Sciences
Two Dimensions of
Quality in Dentistry
• Does the care recommended meet
the profession’s standards of care?
That is, is it the type of care
indicated based of our scientific
understandings and the patient’s
presenting circumstance ?
• Does the care provided meet the
technical criteria, structural and
procedural, for the clinical care
accomplished?
Quality
and
Standards of Care
• Standards of care (practice
guidelines) are systematically
developed statements to assist
practitioners and patients in making
decisions about appropriate health
care for specific clinical situations.
• A standard of care includes:
–
–
–
–
Goals of therapy
Indications for therapy
Contraindications for therapy
Considered risks
Quality
and
Standards of Care
• Standards of care are developed by various
professional organizations.
– American Heart Association
– American Dental Association
– Dental specialty organizations, such as
• American Association of Oral and Maxillofacial
Surgeons
• American Academy of Pediatric Dentistry
• American Academy of Periodontology
• Standards of care are typically developed
by representative clinical committees
based on the research evidence available
for the most appropriate management of a
given clinical situation.
Quality and
Technical Criteria
• Not only is it a requirement of
ethics that the recommended
therapy be within the
profession’s standard of care,
but the therapy provided must
be technically appropriate.
• Examples of such quality
failures include: overhanging
amalgams, fixed prostheses in
or incorrect occlusion, open
margins on fixed prostheses,
etc.
Major Caveat
• None of us perform technically
perfect clinical dentistry all of the
time.
• We are human—we make mistakes.
• However, professional ethics
requires that we acknowledge and
correct those mistakes when they are
identified.
• Never promise a patient anything
except fidelity/faithfulness.
• “I will be there for you should
problems with my care develop.”
Quality of Care and
Lifelong Learning
• The French call it L’informatique,
the explosion of knowledge our
world is experiencing.
• 6,000 - 7,000 scientific articles
published every day.
• Now … scientific and technological
information increases 13% /year -doubling every 5.5 years.
• Rates of information expansion will
soon increase 40%/year due to more
powerful information system and the
increasing population of scientists.
• Then … the scientific information
will double every twenty months.
ADA Principles of Ethics
and Code of Professional
Conduct
There are three main components:
•
•
•
Principles--are aspirational
goals of the profession
Code of Conduct—expression
of specific types of conduct
required or prohibited
Advisory Opinions—
interpretations of the Code by
the ADA Council on Ethics,
Bylaws and Judicial Affairs
ADA Principles
• Patient Autonomy
“self-governance”
• Nonmaleficence
“do no harm”
• Benefience
“do good”
• Justice
“fairness”
• Veracity
“truthfulness”
Fidelity
• Fidelity is faithfulness.
• As indicated previously, the root
meaning of profession is “to
profess,” to “make a promise.”
• Inherent in the promise of the dentist
to the patient is the commitment to
be there for them, to place their
interest as primary; to do for them
the best that can be done with regard
to oral health care, and to not
abandon them in time of need.
Abandonment
Abandoning a patient is a moral
issue, but laws (again, based on
the moral principle of justice)
also apply.
Essential Elements of
Abandonment
• There is an established
dentist/patient relationship. This is
established by minimal contact, such
as a telephone call to schedule an
appointment.
• There is a reasonable reliance on the
part of the patient that care will be
provided.
• There is a need for care by the
patient, such that lack of care will
result in some degree of harm.
Abandonment Potential
• A dentist refuses to treat a patient without
giving necessary and proper notice of
unwillingness to continue to treat so the
patient can locate another dentist.
• A dentist removes self from operatory
during a procedure, or fails to attend to a
patient subsequent to treatment.
• A patient is not observed often enough to
recognize potentially harmful
developments in tome to treat.
• A dentist fails to give proper instruction
regarding a patient’s care subsequent to
leaving the office.
• A patient of record is in need of urgent care
other than during office hours and no
arrangements have been made for the
dentist or a colleague to see the patient.
Grounds for Terminating
Relationships
• Lack of cooperation by the patient.
• Lack of agreement on appropriate
goals or methods of treatment.
• Intervening illness of the dentist.
• Lack of payment by the patient.
• Mutual consent.
• Actually any reason that is not
discriminatory, that is, based on
race, religion, sexual orientation, or
HIV status.
Terminating a
Patient Relationship
• Attorneys advise that when there is a
desire to terminate a relationship
with a patient that it is wise to sent
the patient a certified letter, return
receipt requested, advising them that
as of a date two weeks hence (some
suggest four weeks) you will no
longer be able to be their dentist.
• No reason has to be given for the
dissolution of the relationship.
Confidentiality
• If patients could not trust dentists to
conceal sensitive information,
patients would be reluctant to
disclose full and forthright
information.
• The duty to maintain confidentiality
is also supported by the basic right to
personal privacy.
• The Health Insurance Portability
and Accountability Act of 1996
(HIPPA) reflects society’s general
concern about the privacy of
personal health records.
Professional
Self-Regulation and
Justice
• Professional self-regulation is an
onerous obligation, and difficult to
achieve. The duty to colleagues
seems, at least superficially, to take
precedence over the obligation to
patients in matters of professional
incompetence.
• To the extent that concern for other
dentists prevails over concern for the
clinical mismanagement of patients,
professional ethics is reduced to
“courtesy within a guild.”
“In order to guarantee to the public that
certain standards shall be maintained, the
state limits the license to practice to those
who have completed a course of
professional education. Professionals as a
group profit from this state-created
monopoly. They fall short of their
responsibilities for the maintenance of
standards if they merely practice
competently and ethically as individuals.
The individual’s license to practice
depends on the prior license to license,
which the state has, for all intents and
purposes, bestowed on the profession. If
the license to practice carries with it the
obligation to practice well, then the license
to license carriers with it the obligation to
judge and monitor well. Not only the
individual, but also the collectivity
(profession) itself is accountable for
standards.”
William F. May
• However, a cautionary note is
advised. It is a violation of the
autonomy of colleagues, that is, a
limiting of their freedom or
opportunity, if comments are made,
or actions taken, without complete
surety of the facts of the case.
• Documentation of repeated breaches
of professional behavior by
colleagues demands that the “whistle
be blown.” The profession’s
covenant with society requires the
profession to act vigorously in
maintaining its moral integrity.
• Depending on the issue, colleagues
should be reported to the component
or constituent dental society, or to
the state board of dentistry.
Professional
Fraud and Abuse
• Fraud is “making false statements or
representations of material facts in
order to obtain some benefit or
payment for which no entitlement
would otherwise exist.”
• Abuse is “any practice that either
directly or indirectly results in
unnecessary costs.”
• It is estimated that approximately
10% of the nation’s dental care
expenditures are based in fraudulent
and abusive practices.
• If expenditures for dental care reach
$80 billion this year, this means that
$8 billion is fraudulent or abusive.
Types of
Professional Fraud
• Billing for services not provided
• Billing for unnecessary services
• Billing for services provided by
unqualified or unlicensed clinical
personnel
• Knowingly billing for inadequate or
substandard care.
• Misrepresenting the nature of
services provided
• Waiving of insurance co-payments
• Soliciting/receiving or
offering/paying remuneration to
induce referrals.
Types of Abuse
• Failure to follow clinical
guidelines or standards of care
• Providing unnecessary or
substandard care
• Violating insurance
participation agreements
• Making false statements or
representations
Worth Noting from the
ADA Principles and Code
• Dentist has an ethical obligation
to furnish a copy of the patient’s
record, including radiographs to
the patient, at no or nominal
cost, regardless of whether or
not the patient has an
outstanding balance on their
account.
• Dentists are obligated to
become report suspected cases
of abuse and neglect to
appropriate state authorities.
Worth Noting from the
ADA Principles and Code
• A dentist may not refuse to treat a
patient with a bloodborne pathogen,
Hepatitis B, C, or HIV, based solely
on that fact. Not only unethical, but
also illegal.
• Dentists are obligated to make
reasonable arrangements for care of
patients not of record, when
consulted in an urgent care situation.
• Dentists are obligated to report to an
appropriate reviewing agency
instances of gross or continual faulty
misconduct by other dentists.
Worth Noting from the
ADA Principles and Code
• It is unethical (and illegal) for a
dentist to waive the co-payment of a
patient who is under a third party
payment agreement.
• It is unethical (and illegal) for a
dentist to alter a date of treatment in
order that a patient can receive
benefits of a dental plan for which
they would not otherwise have been
entitled.
• It is unethical (and illegal) for a
dentist to describe a procedure
incorrectly on a third party payment
form in order to receive a fee that
would not ordinarily would have
been paid, or to receive a higher fee.
Worth Noting from the
ADA Principles and Code
• A dentist may not advertise or solicit
patients in any form of
communication in any manner that is
false or misleading in any material
respect.
• The use of fellowships, e.g. FACD,
may be misleading to the general
public and indicate special skill or
education. Unearned or honorary
degrees and fellowships should be
limited to curriculum vitae or
scientific papers.
Worth Noting from the
ADA Principles and Code
• Dentists may only announce as specialists
in one of the nine specialty disciplines
approved by the ADA.
• The Supreme Court has ruled that the
expression “practice limited to” is the same
as “specialist in” and cannot be used
except by qualified specialists.
• It is unethical to announce that one’s
practice is limited to cosmetic dentistry or
that one is a specialist in oral facial pain or
tempromandibular joint disorders.
• General dentists may announce all of the
areas of oral health care they offer, as long
as they do not say or imply that they are
specialists in the field. For example, a
general dentist may indicate that s/he
practices general dentistry, including
pediatric dentistry and orthodontics.
Professional Ethics
Summarized
• Professional ethics is based on the moral rule “do
your duty.”
• In the dentist-patient encounter, the dentist has an
obligation to treat the patient justly (fairly) by:
providing an oral health benefit which is both
desirable for the patient and agreed to by the
patient. This is done by gaining a valid informed
consent.
• The dentist also has the obligation to deal fairly
with the patient by being faithful to the promises
made to the patient, being honest, providing quality
care with the standards of care of the profession,
being impartial in selecting and treating patients,
safe guarding the patient’s privacy by maintaining
confidentiality, and not abandoning patients.
• Dentists have the further ethical obligation of
maintaining their knowledge and skills current in
order that their patients are able to receive the
highest quality care the profession can offer based
on current scientific understandings.
Discussion
and
Questions
David A. Nash D.M.D., M.S.,
William R. Willard Professor of Dental Education
Professor of Pediatric Dentistry
College of Dentistry
University of Kentucky
Email: [email protected]
Telephone: 859.323.2026
A Theory of Justice
• Rawls understands justice to exist in two senses:
– Justice in inter-personal relationships.
– Distributive Justice, how are the benefits and
burdens of society to be fairly distributed?; or
what is generally understood and referred to as
Social Justice; and
• In both senses, Rawls is concerned with justice as
fairness.
Social Justice
•
Rawls’ understanding of the nature of justice
(fairness) in social context
•
Famous hypothetical:
“veil of ignorance”
•
Rational humans designing a world into which
they would be born, based on a natural lottery,
would be somewhat risk aversive, and would,
therefore create a world with three conditions:
1.
All would have equal rights and liberties.
2.
Equal skills and abilities will have access to
equal access to the various positions of
society; and the most important one for our
consideration today. Resulting differences in
status and welfare would be “unfortunate,”
but not “unfair.”
3.
Social and economic institutions would be
so arranged as to maximally benefit the
worst off.
Social Justice and
Dentistry
• Given a Rawlsian view of justice/fairness,
the profession of dentistry—as a social
(and economic) institution—and one with a
virtual monopoly to practice, has an
obligation to work for a health care scheme
that permits the “worst off” in society to
gain the benefits of oral health.
• Rawl’s contractarian approach to justice in
(oral) health care can also be supported
when viewed from the perspective of the
three other major theories of justice:
utilitarianism, egalitarian, and libertarian.
Access to Care
• To what extent do the socially underprivileged
in America have maximum access to the
profession’s resources to assist them in
gaining and maintaining the benefits of oral
health?
• In the United States, the disadvantaged have
the worst oral health and the poorest access to
care. Such is clearly an issue of social justice.
• Such calls into question the reciprocity of the
profession with society, therefore an issue of
justice as fairness—an issue of ethics.
• Society grants dentistry a monopoly to
practice with the potential for significant
financial gain. Does dentistry reciprocate by
ensuring that all members of the society have
access to a decent, basic minimum of oral
health care?
• An understanding of social (distributive)
justice forces the question of how to translate
dentistry’s social “duty” into practical reality.
Access to Care
• The European Enlightenment of the
eighteenth century brought new social and
political understandings. Among these was
the appreciation and valuing of selfinterest.
• However, there was also the realization
that our person, private good is ultimately
grounded in the good of others. Thus
emerged the notion of enlightened selfinterest.
• It is in our enlightened self-interest as a
profession to be concerned about access to
care.
• The monopoly to practice that society has
given us can be taken away.
• Increasingly, public health advocates,
leaders in forming public policy, and
legislators are becoming concerned about
our profession’s inability or unwillingness
to ensure all members of society have
access to the care we can provide.
Access Initiatives
• Dental therapists are currently practicing in
remote Alaskan villages, providing basic
dental care under the general supervision
of a dentist. 53 countries of the world
utilize two year trained dental therapists to
help address access to care problems.
• American Dental Hygienist Association is
aggressively promoting their Advanced
Dental Hygiene Practitioner. Legislators in
Minnesota have filed a bill on their behalf
authorizing such an individual to be trained
and to practice in Minnesota.
• I have advocated adding a Pediatric Oral
Health Therapist to the dental team—a
person working with the dentist to care for
children’s teeth.
• Absent aggressive action by our profession
to deal with this issue of social justice, I
anticipate we will see efforts by society to
ensure all have access to dental care
through methods that are non-traditional.
ETHICS OF
ASPIRATION
“What is the nature of the
‘good life’?”
Life must be lived forward …
but it can only be understood
backwards.
Soren Kiekegaard
Danish philosopher
1813-1855
• What should I value?
• To what should I aspire?
• What should I pursue in life?
• What path(s) should I take?
Alice’s Encounter with
the Cheshire Cat
“The cat only grinned when it
saw Alice. It looked goodnatured she thought; still it had
very long claws and a great
many teeth so she felt it ought
to be treated with respect.
‘Cheshire puss,’ she began,
rather timidly as she did not at
all know whether it would like
the name. However, it only
grinned a little wider. ‘Come,
it’s pleased so far,’ thought
Alice and she went on...
‘Would you tell me please which
way I ought to go from here?’
‘That depends a good deal on
where you want to get to,’ said
the Cat. ‘I don’t much care
where,’ said Alice. ‘Then it
doesn’t much matter which
way you go,’ said the Cat.--’Oh,
so long as I get somewhere!’
Alice added as an exclamation.
‘Oh, you’re sure to do that,’
said the Cat, ‘if you only walk
long enough.’ ”
Lewis Carroll
“WHAT
IS THE
GOAL OF LIFE?”
“To What Should
Humans Aspire?
Aristotle’s answer:
Greek: “Eudaimonia”
English: Happiness/Well- Being
Aristotle’s
Definition Of Happiness
“A complete life, lived in
accordance with virtue,
and attended by a moderate
supply of external goods.”
“A COMPLETE
LIFE...”
“… LIVED IN
ACCORDANCE WITH
VIRTUE”
Virtue in the Greek is
“ARETE” … literally
meaning excellence.
Virtue = Excellence
VIRTUE/EXCELLENCE
understood by the Greeks
as
“FULLMENT OF
FUNCTION”
Virtues
The CHARACTERistics of an
individual’s personality (psyche)
that motivates them to both
rationally control their behavior
by abiding by moral rules, and
to fulfill their nature and
potential as human beings.
To live the happy life, one must
live a virtuous life, which is a
life of excellence; with
excellence understood as:
• Fulfilling the Function
of being a human being,
and
• Fulfilling our unique function
as individual.
Aristotle’s Model
Deficiency
Golden Mean
Excess
Cowardice
Excess Fear
Courage
Strength to
Venture
Rashness
Deficient Fear
Frugality
Miserly/Stingy
Liberality
Generous
Prodigality
Wasteful/
Spendthrift
Abstinence
Austere/
Deprivation
Temperance
Self-Restraint
Gluttony
Greedy/Insatiable
Humility
Pride
Self-Deprecating Self-Respect
Vanity
Arrogant/Boastful
“Virtues are conditions for personal
success within a social fabric.”
Socrates
469-399 B.C.E.
• Truly unique function of the human
is rationality…our self-conscious
reflection of on our lives and their
direction.
• Led Aristotle to conclude that our
intellect/rationality is the noblest part
of our nature.
• Therefore, to truly “fulfil our
function” as humans…to be
virtuous; we must cultivate our
intellectuality--we must be continual
learners.
• Learning, the growth and
development of all of our capacities
through experience is core to our
being. We are learning beings.
“If happiness consists of virtuous
activity, it must be the activity of the
highest virtue,or in other words, of
the best part of our nature…We
conclude then that happiness
reaches as far as the power of
thought does, and that the greater a
person’s power of thought, the
greater will be his happiness; not as
something accidental but in virtue of
his thinking, for that is noble itself.
Hence happiness must be a form of
contemplation.”
Aristotle
384-322 B.C.E.
“… ATTENDED BY A
MODERATE SUPPLY
OF EXTERNAL
GOODS.”
The Ethics of Aspiration
Summarized
• Goal of life is happiness.
• Happiness is well-being; in our
existence to be well.
• Being well is intimately linked to
fulfilling our function as humans.
• Fulfilling our function is
dependent on living life of
excellence, or to use the Greek … a
life of virtue.
Life Long Learning
• Philosophical End
• Psychological End
• Practical End
Philosophical End
• Aristotle advanced a concept of
“intellectual virtue.” We fulfill one
of our vital functions as human
being when we continue to learn.
• “we must cease conceiving of
education (learning) as mere
preparation for later life, and make
it the full meaning of present life…an
activity that does not have worth
enough to be carried out for its own
sake cannot be effective as
preparation for something else.”
John Dewey
American philosopher
Psychological
End
• The distinguished American
psychologist, Abraham Maslow
emphasized the concept of selfactualization-- “being all you can
be.” As we are by nature learning
animals, we actualize our potential
when we learn.
• University of Chicago noted
psychologist, Mihalyi
Csikszentmihalyi’s stated the
importance of “flow,” in a life of
happiness. Having our intellectuality
exercised and stretched with new
ideas, challenging concepts, and
exciting understandings is to get in,
and be in, “flow.”
Practical End
• A competent professional in
dentistry must apply the
profession’s current knowledge
base to patient care with
integrity. Standards of care
must be fulfilled, and those
standards are continuously
changing through research.
• The half-life of dental
knowledge has been estimated
to be 5-7 years.
“If we allow ourselves to become
committed to an elaborate set of
fixed beliefs, we are ensuring
early obsolescence. The
alternative is to develop skills,
attitudes, habits of mind, and
kinds of knowledge and
understanding that will be
instruments of continuous
change and growth. Then we
provide for our continuous
renewal.”
John Gardner
in Self-Renewal
Clinical Scenarios