ACD Gies Project on Ethics in Dentistry
David W. Chambers
Commissioning the project
Why is the project needed?
At its October 2014 meeting in San Antonio, the Board of Regents of the American College of Dentists approved a project to study and make recommendations about improving the practical ethical behavior of those involved in oral health. The project is fully-funded and is expected to require approximately three years to complete.
The model for the project is John Gies’s 1926 Dental Education in the United States and Canada. That report was completed in about six years and resulted in a 500-page publication. Some of the important characteristics of Gies’s approach include the following:
- Almost exclusive dependence on analysis of factual data rather than using the opinions of panels of experts
- Small number of recommendations (the most significant of which were arguably that dentistry not be a specialty of medicine, that it have a grounding in science, and that it be preventive in orientation)
- No sponsorship by professional organizations (the Carnegie Foundation for the Advancement of Teaching provided funding and publicity, but did not seek to have a voice in shaping the findings or recommendations)
The American College ethics project will seek to follow this approach where practice. Because there is no “Steering Committee” other than the Board of Regents of the ACD, a mechanism is needed to inform and engage a very diverse constituency regarding the progress that is being made. The officers of the college have approved the concept of a quarterly bulletin (this being the first example), with eventual systematic postings on a page on the Web site of the college. Initially this report will be sent to the officers and regents of the college, the 30 or more individuals and organizations that responded to the initial announcement in the ACD Newsletter this summer, and fellows of the college who are known to be involved in professional ethics.
Attention has also been given in the past several months to defining the scope of the project. Following the lead of John Gies, who devoted hundreds of pages of his report to developing a concept of dentistry as a professional field, I propose to gradually build a working definition of ethics in oral health. I have begun by enumerating a set of concrete concerns that are not primarily technical, legal, economic, regulatory, or educational but still bear heavily on how dentistry is practiced. The core of these concerns appears to be eroding trust and a tension between commercialism and professionalism, but it is much broader. Gathering factual information about these issues will be the first step in the project.
- What are the common values that hold the profession together; that provide the foundation for its relationship with the public; and that allow it to adapt and grow?
- Are these values shared and are clusters beginning to form? Are they changing, and if so what is causing these changes? Can these values be influenced?
- What are the sources of tension between commercialism and professionalism? Is this relationship changing and is it amenable to influence by the profession?
- How much of what we think of as ethics is based on trust? Is the decline in the public’s trust of the profession incidental or a reflection of changes in society? What builds up and what tears down trust? Can reputation be shared? What are the alternatives to trust?
- Are dentists victims of unfortunate trends in society? Are patients, colleagues, vendors, carriers, corporations, and the government taking advantage of the profession?
- How will the rapidly growing tend toward separation of treatment from management of dental practices affect participating dentists, non-participating dentists, and especially patients?
- Which regulations help oral health and which hurt? Do we understand how regulations play out in practice and how to anticipate longer-range consequences, and can these be influenced?
- Is it really the case that the proportion of Americans receiving care is declining and that this care is less likely to be comprehensive and continuous, and if so, what are the effects?
- Is it really the case that oral health care markets are becoming fragmented (dentists focusing on targeted portions of the population and patients seeking partial care), and if so, what are the effects?
- Is there a workable definition of oral health in distinction to dental treatment?
- What is the relationship between the profession and those who do not attend the dentist (“patients” are per definition not the same as those who need care but those who agree to the terms of treatment offered by dentists)?
- What is the responsibility of individual dentists to the profession generally? Why is membership in organized dentistry continuing to decline?
- How do dentists manage their dissatisfaction with individual members of the profession, the profession generally, and the wider community – interpersonally, legally, through policy work, by complaining? Can dentists be taught to more successfully manage dissatisfaction?
- Have informed consent and standard of care become legal doctrines rather than ethical goals?
- Where do dentists look to get information about ethical standards? When do ethical matters become an issue for them? Of the information available, how do they select guides to actual behavior?
- Although there are multiple ethics journals in each of the fields of medicine, nursing, law, education, management, and other professions, why is there none in dentistry?
- In what sense is it ethical to collaborate with non-professionals in patient care where others do not share common professional ethical standards?
- Does the rapidly growing spread in the range of dentists’ incomes represent a threat to a common standard of conduct?
- What has been the impact of the ADA Principles of Ethics and Code of Professional Conduct?
- Why do practitioners bend ethical standards and break the law? Are there any interventions that are proven to affect this behavior?
Meeting with CEBJA
At the invitation of the ADA, I met with the Council on Ethics, Bylaws, and Judicial Affairs on 13 December. During the meeting I explained the nature of the ACD project and shared the list of practical ethical concerns described above. I also asked for help from CEBJA by their taking three clearly defined actions:
- Designate two individuals from CEBJA to engage with two from ACD, without portfolio, in timely and informal exchange of information regarding ethics and this project.
- CEBJA would notify the appropriate parties and offices at ADA regarding the project and ask for assistance with making available for the project historical and current information such as the Ethical Moments, information about ADA policy and resources, and means of gathering information, as well as any professional expertise that would contribute to the project, to the extent that this is consistent with ADA policy.
- During the data gathering and writing phases and once the report has been released, ACD would like help from the ADA in publicizing all aspects of the project that are not in conflict with the standards and goals of the ADA.
We are hoping for a positive response on all three specific requests in the coming months.
A second reason for the visit to Chicago was to allay concerns that ACD is in competition with the ADA over ethics. A draft letter was circulated during the summer to then current and former members of CEBJA stating that I had shown disrespect to the ADA Principles of Ethics and Code of Professional Conduct. My position is strongly supportive of the code, as expressed generally and specifically in my monthly column on ethics in the Journal of the California Dental Association. I sent a manuscript version of the paper outlining my views to CEBJA staff in the fall and followed with the published column in December. I asked that this be included in the background material available to CEBJA members prior to our meeting, but it seems that did not happen. Download the ADA Code of Ethics.