ACD Gies Project on Ethics in Dentistry
David W. Chambers
Scope of Project
First Study: Dentists’ and Patients’ Views of Common Ethics Issues
This report summarizes progress during the second three months of 2015. The primary focus continues to be developing an appropriate scope for the study and development of fact-finding strategies.
A Wider Net
It is becoming increasingly clear that dentistry is much more than technical skill at chairside. Individual practitioners, especially those in study clubs, the schools, and industry deserve justifiable praise for enormous success in these areas. A glance at the offerings of most large CE meetings is reassuring that dentists have every opportunity to stay on the edge of ever-expanding technical advances. But the state boards, the politicians who channel public sentiment, and a review of the topic in the ADA’s Ethical Moments show that is not where most of the ethical issues are.
Here is the problem. If ethics, or more broadly what is good and right about oral health, is defined in technical terms, dentists can plausibly claim that they have the final and authoritative word about how things should go. By training, experience, and deep concern, we would all be foolish not to listen carefully here. The same cannot be said for all dimensions of oral health. An increasing number of parties want to participate in and have a voice in how dentistry is performed for themselves and their families. Patients, payers, corporate entrepreneurs, regulators, third-party support providers such as marketing consultants and Web page designers, physicians, and even the United States Supreme Court all believe they are entitled to be listened to on the larger issue of oral health. After much reflection, I have come to the conclusion that we need a comprehensive, fact-informed discussion of what is good and right in oral health that involves all concerned. That is the direction I will be taking the ACD Gies Ethics Project.
In 1997, the Carnegie Foundation for the Advancement of Teaching commissioned a series of reports on “Preparation for the Professions.” This was to be an updating of their famous 1910 Bulletin #4 and the 1926 Bulletin #19 on medicine and dentistry respectively. I lobbied to have dentistry included, but the professions chosen were medicine, nursing, law, engineering, and the clergy. This work, now completed, is outstanding.
In his introduction to the report on Educating Physicians: A Call for Reform of Medical School and Residency, Lee Shulman, president emeritus of Carnegie, describes the approach taken by Flexner 100 years ago. Shulman’s introduction can be seen at www.davidwchambers.com/gies-ethics/. Flexner, who was a high school administrator, visited all the medical schools to see what was actually being done. Fifteen years later, Gies, a biochemist, did the same for dentistry. Both reports, which ran into hundreds of pages each, were fact-based.
It would certainly be beyond reason to visit or even get survey information from all dentists and all those who are affected by what dentists do. Both the topics and the sources will be sampled.
Here is a list of some of the questions that can be more clearly framed and partially answered by gathering data:
What is the value structure of dentists?
- Where do dentists get their values?
- What is the role of schools and others in value formation?
- How are values formed in the first twelve years of practice?
- What does the public want and do they think dentistry is delivering?
- Do dentists’ values differ across demographic characteristics?
- Who other than dentists influences oral health, what values to they bring?
- What are the outcome measures most in need of monitoring?
- What should be done when folks see things differently (conflict of values)?
A first example of this fact-based approach has been completed. The second issue of JACD for 2015 is a report of a research project where individuals were asked to respond to eight representative ethical challenges commonly encountered in practice: patients wanting to manipulate treatment and payment, hostile workplace environment, charity care, management of insurance, alternative views of informed consent, etc. Respondents were asked to indicate degree of agreement with several potential actions for each case and to mark reasons for their views. Samples of dentists and patients provided data. There was substantial general overlap on both actions and reason. But there was no unanimity on any point. On many items the range of opinion ranged across the full five alternatives from strongly agree to strongly disagree. There were also systematic differences in the patterns of opinions between dentists and patients. In general, dentists regarded the cases through a technical lens while patients were focused to a greater extent on oral health outcomes.
In addition to providing background facts for the ACD Gies Ethics Project, this work will be available as a learning tool online at the ACD Web site in both written and video formats, with norm data from dentists and patients.
From its inception, it was seen as very desirable to have other dental partners involved in this project. This initiative has included my meeting with the ADA Council on Ethics, Bylaws, and Judicial Affairs in Chicago and a conference call involving members of our Board of Regents and CEBJA representatives. Regrettably it does not appear likely that our collaborative efforts will include CEBJA due to their commitment to other projects. The College regards this as a missed opportunity.