ACD Gies Project on Ethics in Dentistry
David W. Chambers
Where will the data come from?
This report summarizes progress during the first three months of 2015. The major accomplishments have been to expand the definition of the role of ethics in oral health and to begin identifying sources of data.
Defining the Issue
On the broadest possible understanding, ethics involves making choices where more than one person cares about and uses standards to judge whether the right thing was done. Roughly, any question that can be framed “Should we do this…?” involves ethics and will potentially be part of the ACD Gies Ethics Project if it affect oral health.
What is in the conversation and what can we safely ignore? Obviously the choices individual dentists make that affect others should be part of the inquiry. But moralizing – commentary on “how the world would be better if other people did what I think they should” – looks like a waste of time. It also seems as though there is something to learn about groups as well as individuals. “Dentistry,” as a profession, should interact in the right way with the rest of society. Dental groups should interact with other dental groups. Individual dentists and people who are and are not patients may not agree with all the standards in the profession but they should be influenced by them. Thus there is both a micro ethics and a policy ethics. It is probably not realistic to assume that hard work at the micro ethics level will be sufficient to manage the policy ethics issues or that good policy will make good dentists.
Honoring the spirit of William Gies, this project will remain close to the data.
Values: Surveys and case scenarios will be used to find out what dentists of varying demographic and practice conditions value. The values of patients, those who are not patients, students, policy makers, leaders in dentistry, and the dental support industry will also be gauged. To the extent possible, the focus will be on identifying value-driven behavior and differences in value profiles of the various members of the oral health system. Ethics is a value-maximizing business.
Value: Knowing the values of individuals in the oral healthcare system will provide an incomplete picture of how it should be functioning in its most ethical sense. How the parts fit together matters. It will be easy to document the marvelous advances over the past half century in the oral health of America. Think of it as a pie that has, at least until five years ago, been growing at a spectacular rate. But there are value questions regarding the shape of the pie, the distribution of benefits and burdens among the agents participating, and even of the entry of new agents such as insurance and commercial interests. These value characteristics have ethical implications, especially at the policy level and into the future. These also provide a changing context for the micro ethics of daily decisions by individuals. The data for this analysis are in aggregate databases and organizational policy documents.
Accessing the Data
Flexner (the first Carnegie Foundation report on medicine in 1910) and Gies (the only Carnegie report on dentistry in 1926) both used a saturation sampling technique. The authors visited all medical and dental schools in the United States and Canada over a several-year period. Obviously nothing like that could be done in the present situation. Sampling design thus becomes a critical issue. The most recently completed round of Carnegie Foundation studies of “preparation for the professions” (separate studies of medicine, nursing, law, engineering, and the ministry) abandoned the comprehensive approach in favor of structured sampling.
Modern computerized survey methods and databases in large organizations are convenient, but pose methodological risks. Although they offer reach, there are problems with representativeness. A large response rate on a national sample asking individuals to report on their ethical behavior is likely subject to response bias. Further, all of the organizations that matter in shaping organizational policy do not operate at the national level.
I propose to begin by working very closely with perhaps four states that are representative in terms of geography, size, economic base, insurance coverage, ADA membership, urban-rural split, and political style. The structure of dentistry in these states and in selected component societies within them would be studied more intensely than could be done by sampling at a national level. The activities of the groups that affect the value proposition of oral health would be characterized in interviews and observation, and these organizations would, it is hoped, place me in contact with individuals to be surveyed for their values. This method would permit a more valid data collection process as well as one that coordinates data from individual values and group value perspectives (micro and policy ethics).
There are two other studies currently under way of a similar nature. The American Dental Association is responding to a House of Delegates charge to explore the impact of student education debt on practice choices. There is also a major study intended to project the nature of dentistry in 2040 and the changes needed in dental education being led by Drs. Howard Bailit and Allen Formicola.
Steve Ralls, executive director of the college, and I have met with Dr. Bailit and we have had additional correspondence. We have agreed to share data and working drafts of our projects and to have a joint meeting of the principals involved individuals soon.
A group of experts on dental economics, workforce trends, and patient health outcomes is being assembled.
Preliminary contact has been made with leaders in three states who have expressed interest and potential willingness to participate in this ACD-sponsored project.