Transcript The Terrain of Ethics

Dentistry as a Business in
Tension with Dentistry as a
Profession
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.