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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Dentistry knocks often on the doors of professional promises. Dental education often opens them, and always finds a warm welcome. Seldom, however, are the rooms behind the doors of professional promises paid an extended visit—a visit that remains warm and hospitable, with enough time and space to reveal the keys to other rooms in our lives and in the world. This special issue of the Journal of Dental Education reports on visiting one room that can be entered through several professional promises: that room is access to dental health care.
The authors of articles published in this special issue were simply the first visitors invited to join a three-phased project on the ethics of access to care, a work in progress. The first phase was the workshop itself, held in Chicago in August 2005; the second, a report of the project to the American College of Dentists in October 2005; and the third, still in progress, a larger forum to advance its findings and put them to practical use. We invite you to become part of this third phase by exploring, playing with, and working with the contents of this room on access to oral health care. It is our hope that your experiences with this visit will continue. We promise that it will not only raise hopes and close gaps in access to oral health care, but will raise your awareness about the living dynamics of the professional, organizational, and systems ethics that frame our culture and way of life.
The hope of professional promises lies within every professional and anyone who supports the need for professions. Drs. Catalanotto and Patthoff, in their introductions, offer two different but parallel accounts of how they, as dental professionals, were brought together to become catalysts for this first visit. Their stories offer the first inklings of how we as individuals and together can understand and address a very complex systems challenge. They also answer these questions: Why are we doing this? How did this get started? Who gave us support?
Dr. James Crall presents an overview of the hard data of access issues. He goes beyond simply revealing the health, social, and economic concerns of access to care, but gets at the personal pathos of children, the aged, and the disparities related to race and economics.
Dr. David Ozar then gives voice to two fundamentally different understandings of what we mean by "I want" and "I need." His overview of what we might mean by "ethics, access, and care" is responded to by Dr. David Chambers. Together, the two provide insights into these basic terms that are surprising and rewarding. When asking "What are the consensus definitions of the words access and care?," for example, are we dealing with words that are too political or too broad for developing and implementing a specific applied ethical tool common to professional codes of ethics and core values?
Dr. Brian O’Toole expands on these definitions, describes the need for professions, and helps us see differences in the roles of personal, professional, and organizational ethics. How are they imagined and discussed? How can they guide ethical behavior? In a companion article later in the issue, he introduces an exercise that quickly reveals natural ethical instincts. This exercise is a sound tool with practical uses: it brings ethics to life and helps each of us hear those who have different forms of moral imagination. When carried out in small groups, the exercise becomes food for the brain and heart and betters our conversations. Principles, character, or the bottom line are not all there is when it comes to talking and doing ethics, and Dr. O’Toole’s short test generates some curious and practical insights.
The public priority of basic oral health needs is seriously questioned by Dr. David Ozar. After viewing the alternatives, Dr. Ozar and Drs. Larry Garetto and Karen Yoder demonstrate its priority and, in the process, suggest which priorities might be addressed by ethics and professional promises. Why focus on improved access? What makes it good? Can it harm? Dr. David Smith, a layperson in terms of dentistry but a well-known philanthropic ethicist, explores why dentistry can do things and must do things that the public cannot. His article separatesone-time charity deeds from long-term philanthropy, and he urges dentistry’s exploration of philanthropy, which now contributes more to the total gross national product of the United States than either government or commercial dollars and is thus changing who and how social needs are met within the Great American Experiment. Dr. Wendy Mouradian, a physician, furthers the discussion, showing why volunteer efforts and "band-aids" are inadequate for a problem that became, in 2005, the number one health problem facing pediatric physicians. Dr. Caswell Evans, the key editor behind the U.S. surgeon general’s report, Oral Health in America, adds his unique and personal insights into a crisis that threatens to segment rather than unite people and professionals.
Dr. Patricia Werhane turns our gaze on access to the practical questions of responsibility and funding by introducing, in clear but sweeping motions, the reality of systems thinking and, more importantly, the need to understand and consciously choose the organizational and systems ethics that frame professional and public cultures. Dr. Ozar refers to Dr. Werhane’s early work on systems thinking, which is already part of mainstream business, and points out why it is the step most worth taking and why, once taken, it will always remain a work in progress. Still, they ask, can the participants of a workshop or discussion identify political, social, economic, and applied ethics tools devoted to the pursuit of justice and improved access to care? Is access to health care a human right? Is it a commodity? What are the political, social, and professional implications to health care as a human right?
Dr. Bruce Corsino, with Dr. Patthoff, then introduces the two notions of 1) acceptance as an ethic and 2) universal patient acceptance as the key core value for consciously guiding any organizational and systems ethics interested in closing the access gaps to oral health care. They carefully demonstrate why, as a person becomes a patient, it is important to segment access to acceptance from access to diagnosis, treatment, and payment. Dr. Beverly Largent responds not so much to the specific ethics of acceptance within professional codes of dental ethics, but rather to the role of the American Dental Association and organized dentistry. She describes the history of organized dentistry as the leader for bringing access to oral health care to the prominence that it now holds. She explains why acceptance should be given a closer look within the profession and cautions us to possible results when it is misunderstood, misused, and/or applied too soon to the areas of diagnosis, treatment, payment, or to all four steps of being a patient. Further discussion within the conference, and not fully reflected in these articles, addressed these questions: How are acceptance and related topics reflected in codes of ethics? If not made explicit, is there a consequence for such silence? What are the key features of the ethics of access?
Dr. Bruce Graham, a dental dean, explains why some methods of teaching ethics are ineffective in educating dental students about oral health care access disparities. He provides models of experiential off-site programs that show promise if the participating students can actually enter into, and help create, the professional culture needed to address disparities among the patients they meet. Dr. Phyllis Beemsterboer’s response targets additional best practices to develop an ethic of access to care in dental students.
Amy Tuttle-Morgan of the Pride Institute presented at the workshop the ways practice management companies handle access-to-care issues in their continuing education programs. She argued for why these programs need to be an integral part of any overall access-to-care effort, but did not address the challenge of universal patient acceptance or submit a paper. Dr. Bruce Peltier’s response, however, articulates the basic difference between commercial and professional trust: the commercial promise built on competition, and the professional promise built on collaboration. He proposes how they can be complementary if the professional promise is given priority and a common understanding of acceptance guides the partnership. How do multidisciplinary experts, he asks, contribute directly to the ethics education of dentists?
Drs. Chambers and Dharamsi present two important articles on discourse ethics or how talking and writing shape our communities, asking how systems see their place in education. Their articles not only hint at different kinds of discourse, such as scientific, philosophical, political, narrative, economic, and religious, but how those kinds interact to make us partners in creating professional communities. Dr. Chambers proposes four models of treatment currently discussed in dentistry: 1) traditional oral health care, 2) oral care that has minimal or no health component, 3) episodic medical care, and 4) oral health outcomes not resulting from dentist interventions such as fluoridation. Each of these models defines care and access differently, therefore demanding that dental practitioners find ways to avoid becoming segmented so they can better partner with society and lead with a coherent voice.
Dr. Dharamsi introduces some important philosophical discourses that are part of our professional and social culture and addresses how they can be qualitatively measured. Better education in this area is critical, he says, to helping the profession better match the dominant philosophical school to the appropriate steps in access issues. Collaboration and the rule of the commons (egalitarianism), for example, guide the ethic of acceptance across religions and philosophies; they meet the practical test of John Rawls’s hidden veil approach to the golden rule. Individualism and the rule of competition (libertarianism), however, hold priority in the United States when it comes to money and reimbursement systems. When looked at closely, compromise becomes obsolete, and collaboration for the greater good becomes the better promise.
Prof. Pamela Zarkowski closes this special issue by summarizing the workshop deliberations and identifying future forums for presenting its results. She discusses how these might impact other forums such as one on commercialism that followed several months later at the ADA in Chicago.
The articles in this special issue—and the conference papers on which they are based—were invited and developed specifically for dental professionals. They represent some of the most knowledgeable and experienced people working with these ethical and commercial issues within and outside of dentistry. The background to the work that supports their prose fills libraries. The articles themselves, then, are distilled, still evolving within the authors, but ready for your review.
That is a benefit. Feel free to use them any way you want. The overall integrity of this special issue of the Journal of Dental Education, however, is the acceptance of individual people and their well-being as the object to be held in our hearts and the reason for any professional promise. People talking with people, in warm and hospitable rooms, brings life and dynamics to our professional community and the partnerships we must make with society.
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Acknowledgments |
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We, the editors and authors, appreciated the many and varied outside reviewers who worked behind the scenes to evaluate, challenge, and add new insights to each of these papers that brought them to their rich and present form.
And finally, from Frank and Don, many thanks to Carolyn Gray, who has provided wonderful administrative and editorial assistance. Carolyn has been with us since the conceptual beginnings of this project.
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Footnotes |
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This article has been cited by other articles:
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  Curriculum and Clinical Training in Oral Health for Physicians and Dentists: Report of Panel 2 of the Macy Study J Dent Educ., February 1, 2008; 72(2_suppl): 73 - 85. [Full Text] [PDF]
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