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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Key words: acceptance, access to care, dental ethics, discourse ethics, ethics, oral health, public professional partnerships, systemization, universal patient acceptance, volunteerism, moral imagination
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Abstract |
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 Top Abstract Preventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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Alasdair MacIntyre, in Three Rival Versions of Moral Inquiry,1 argues that history and morality are interconnected and why a history structured on a future good is more informative than one based on either my or your or any other person’s or group’s personal history. It cannot, then, only be structured as a story from the past to a later point in time using today’s insights as the key guide. This is focused on an inquiry into the future good of acceptance within systems ethics. Quo Vadis—that is, where are you going?
The invitation to this workshop says it will examine the core ethical issues related to access to oral health care for underserved, indigent, and otherwise vulnerable populations. It aims to examine how the dental profession itself can better integrate access, justice, and other values into its moral system of community service so that the professional responsibilities that come with professional rights can be enhanced. Exploring the concept of "acceptance" as one of the core ethical values that are unique and practical to the health professions promises is key to discussing the rest. I want to emphasize here that it is a positively stated notion, not a negative one. That is, just like asking your pediatric patients to focus on being still and quiet is more helpful than saying don’t do that or don’t move, articulating acceptance as a positive form of moral imagination is more helpful than saying something similar with a negative phrase like "don’t discriminate." "Don’t discriminate" may at first be taken as a universal statement, but then practicality comes into play because each of us must prioritize the focus of our attention and we must judge and discriminate. Therefore, specific forms of discriminating need to be spelled out more clearly when they seem to be more important. We do this by adding specific reasons for not discriminating, such as for race. Then, additional reasons can be listed, such as for creed, color, form of insurance, type of disease, etc. As the list of reasons for not discriminating grows, so too does the creativity for finding reasons and perhaps needs for discriminating.
Before I go on, it will help if I briefly say something about what I mean by the concepts of "acceptance" and "patient acceptance." The noun "acceptance" is a distinct kind of ethic. The nature of that ethic should become clearer by the end of this article. Patient acceptance, however, is an act that health care providers do within this broader ethic of acceptance; it describes how a person is first received when he or she expresses a desire to be a patient or needs help with health care.
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Preventive Dentistry Research and Acceptance Awareness |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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During those years, many of us involved in these preventive dentistry efforts also developed a state program for measuring the brushing and flossing skills of third and fifth graders in public and private schools. I went into the measuring and evaluating because it was a spin-off from some work I did as principal investigator of a health services research grant to evaluate preventive dentistry for VA patients. That research grant had some relationship to the Health Belief Model and the patient education research that was coming out of Johns Hopkins University. One dentist I know, however, said he got involved with the local school education effort for more practical reasons: it was a good way to convince teachers that they needed dental insurance, and a large portion of his practice had teachers as patients.
His practical reasoning had some place in my thoughts. This is because, as a new researcher, my major research question was a very broad practical question: it basically asked if the effort of teaching people usual and customary preventive dentistry was actually cost-effective and cost-beneficial in reducing dental disease. The advisors who were reviewing my methodology, however, said I could not practically accept every patient as a research subject but had to select qualified candidates to answer more specific points about the educational package. It was my first awareness about the notions and roles of universal, selective, and random acceptance, but it was not labeled as such at that time.
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An Insurance Crisis, Acceptance Articulation, and Systems Ethics |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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I first learned about and experienced systems ethics and how much power it can harness in this very real complex insurance situation in 1986. It was my second week as president of the WVDA, and our state legislature thought it would be a good idea to pass a law requiring, in effect, that all insurance companies in the state must sell liability insurance to anybody who applied for it at a fixed rate. Lloyds of London, which underwrote most of that kind of insurance product for those companies that sold in West Virginia, said they would no longer contract with any insurance company that sold products in the state. They said that they designed their product with the promise of the state having certain restrictions in place that would allow them to select their customers and set profitable rates. Since the state changed its law, the state had broken its promise, and, therefore, the insurance industry could no longer honor its contracts.
As a result, obstetricians, orthopedic surgeons, and other physicians along with a few dentists, not being able to get financial protection, closed their doors, sold their homes, suffered major losses, and left the state. Voters and patients went up in arms. The emotions and name-calling about insurance, law, and medicine hit the front pages. The dispute even took the form of physical brawls in hotel conference rooms.
My first state dental meeting agenda, which had been planned to focus on prevention, was suddenly trashed. My executive director, Richard Stevens, and I talked more about actions we could take for dentists. We were getting nowhere on our first question: what was the problem, and whose problem was it? In terms of dentistry, our state organization, and this meeting, it was our problem—most specifically mine, since I was charged with setting the agenda for the meeting. The more I struggled with it, the more I knew it was not a purely legal, political, educational, economic, or scientific problem, because emergency rooms and dentists that stayed behind in the state still had to accept and see people for emergency care even if insurance companies would not accept their premium payments. The state legislators and executives at first said they would underwrite the policies for the insurance companies. They quickly learned, however, that they were not solvent enough to operate as an insurance company and would need to get someone to underwrite them. Lloyds of London, being an international business, was not held only to U.S. law and influence and needed a chance at profit to stay in business. And, even though it was the only agent capable of underwriting the state’s proposed self-insurance venture, Lloyds said no. It and the insurance system as a whole said they would reconsider, however, if the state made the legislative promises needed so the insurance industry could compete fairly in the market. The state said it would not be held hostage by an industry and refused. People, however, still desired and needed health care. Those health care providers who promised to provide care to those in need and stayed did provide that care; some doctors, however, began to focus more on the public’s desire for adequate care than their desire for best care. Managed care, and its use of adequacy as the boundaries for what should count as reasonable care, is further evidence of this trend.
One year earlier, in 1985, at the time of the annual state presidents-elect meeting at the American Dental Association (ADA) in Chicago, West Virginia had one of the lowest dental malpractice insurance premiums and one of the highest medical malpractice premiums in the country. Because West Virginia did not have a dental liability insurance premium crisis in 1985, I did not sign up for the session dealing with insurance matters. I was, therefore, totally caught off guard, as were the leaders of related dental associations, when this crisis arose early in 1986.
When I called the ADA’s Council on Insurance, I was referred to the Council on Ethics, Bylaws, and Judicial Affairs (CEBJA). I was advised that I had an ethical problem and needed an ethicist. "What’s one of them and how do you spell it?" I asked. At the time, there were only two dental ethicists—a philosopher and a psychologist. David Ozar, the philosopher, was the first to answer his phone.
Dave said he could not come to West Virginia because of teaching obligations. After listening to my story, however, he had a few suggestions. In effect, he said this was a level of ethical questioning that few people have thought about, but it needs to be done and that there are some good tools to work with. He then identified the key players who needed to be brought together and formulated the key questions that needed to be asked. I presented my discussion with Dave to the WVDA executive director. He said he would contact the key players and get the additional invitations out so they could participate in our first state dental meeting for 1986, which was the following week. He also reminded me that I would be in charge of going through the questions and keeping the protocol on who would speak first.
On the day of the meeting, the full board of the dental association came into session. Our invited guests included the West Virginia state insurance commissioner, the leader of the West Virginia House of Delegates, the West Virginia medical and hospital associations’ leadership, and several others. The goal of the session was to provide focused uninterrupted dialogue about what each party needed to settle the crisis. Because of the need to maintain authentic dialogue from several areas of expertise and authority, one of the assignments given to me as mediator by the group was to ensure that any interrupter be removed from the room. In a matter of three hours, after we’d dismissed only two dental association council members, each representative group made promises about what they could do to help move things in a different direction. Nothing big was promised by anyone. The insurance commissioner, for example, said he could be more flexible in interpreting an area of concern about who the state could accept as clients as expressed by the insurance company representative; the state legislative representative said he would talk to the leadership of a legislative committee about the competitive nature of insurance and insurance companies’ need to selectively accept their clients; the executive director of the hospital association said he would send a letter of explanation to all the hospitals and explain that the need for insurance companies to selectively accept their clients was not the same as hospital emergency rooms needing to see all emergencies. (This difference, by the way, gained judicial support several years ago from twin, same-day U.S. Supreme Court decisions. Emergency rooms can’t cherry pick or dump emergency patients based on the patient’s definition of an emergency, and third-party carriers have a right to decide which emergencies they can cover under their benefit packages.)
All together, things thawed very quickly, and our association received praise from the many people involved who also asked how we did it. At the time, neither our state dental association’s executive director nor I really knew how it worked or why. Now, looking back, it was one of our first experiences with 1) deliberative discourse, 2) the significance of identifying and selecting chief clients, 3) asking and prioritizing the right questions starting with "whose problem is it?," and 4) applied systems ethics.
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The Continuing Education of Dental Ethics and Motivations to Act |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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In a sense, this was my first real experience with applied ethics and its practicalities at a systems level. It was something different from politics, religion, economics, law, or science, as I understood them. I asked Dave where I could learn more, and he said that a small group of people who were asked to teach ethics in dental schools had just started a volunteer group to teach themselves what they were being asked to do by other dental educators who, for some reason, thought it was a good idea to teach ethics to dental students. I went to my first meeting of the group in 1986 and found myself the only general practitioner in private practice. I was also the only person not primarily interested in teaching students. Dave, John Odom, and Muriel Bebeau welcomed me and promised to help me explore the continuing education of ethics for practicing dentists. The group began to call itself the Professional Ethics in Dentistry Network (PEDNET).
When I got back with the ADA on this subject, I was told that my idea about teaching ethics as continuing education for practicing dentists was very important but not something CEBJA had, as of that time, made a priority. Part of the problem was that they didn’t have anything practical to work with; they had lots of theories, but nothing with a track record.
Robert Biddington, then dean of the West Virginia University School of Dentistry, was also immediate past president of what is now the American Dental Education Association as well as president-elect of the American College of Dentists (ACD). He was very passionate about ethics, but said he too only knew about the teaching of theoretical ethics and thought something needed to be developed with applied ethics—that is, ethics developed in a way that would have a positive predictable impact on health care outcomes and dental practice. He introduced me to several people he knew: John Odom, Muriel Bebeau, David Nash, and the late Thomas Hasegawa, among others, which was the same handful of people I had met at the PEDNET meeting.
I searched for funding of ethics projects and specifically the continuing education of professional dental ethics. At that time, I quickly learned that my particular interest was not a fundable item within the profession or the National Institutes of Health and that it was not an acceptable category of credit for state dental continuing education requirements. I eventually was led to the West Virginia Humanities Council. With some begging and arm-twisting, the WVDA accepted a small grant from the humanities council to develop an applied dental ethics course for dentists on real ethical issues in their practice. John Odom and Carolyn Gray offered some tips as a result of their plans for developing curriculum guidelines for teaching ethics in dental schools. With that information, we were able to put together a seminar that involved David Ozar, along with a philosopher, an English literature professor, and a sociology scholar.
Bob Biddington, wearing all his hats, came to the seminar and decided it was a huge success. Those in attendance and the evaluator—a philosopher and humanities scholar who was sent from the National Humanities Council—confirmed that assessment with his qualitative tools. Bob asked for my workbook and the report we sent back to the humanities council that detailed how the session worked. When he took that information to the ACD, I was invited to present something similar at its next annual meeting. After its success, David Chambers said we should think much bigger and that a few members of the ACD were already exploring ways to do so. Over the next year we did a few more leadership skills sessions through the ACD, and it became obvious that we needed to train the trainers. That led to the first Intensive Ethics Course for Dentists, held at Georgetown University; it, in turn, developed into a semiannual training session for dental school ethics educators, organized by David Ozar and Tom Hasegawa and held at Loyola University in Chicago.
On a parallel track, the ACD was organizing dental ethics summits and brought in the ethicists within PEDNET as consultants. After the second summit, it became obvious that the eighty-eight organizations that represented the greater dental community highly valued the space and time to discuss the kinds of questions they were not able to in boardrooms, the marketplace, or anywhere else. The group also wished to include patients and political interests in the future.
The notions of access and how patients are accepted into the dental care system surfaced periodically in those meetings as a potential commonality and desire. All involved, not just dentists, thought it was most important to respond to pain, the "May Day" which comes from a French phrase meaning "please help me" (aidez-moi). Its origin is with independent fishermen. When they went out to sea and found themselves in circumstances where their independence and reliance on their own skills and knowledge was not enough for their survival, they needed a call that would convey the seriousness of their need. The answer to the common question about who decides what in an emergency is simply, then, that the person thinking he or she has the emergency makes that decision.
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Core Dental Ethics Summit Discourse: Values and Acceptance As Acts |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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A side note will be helpful here. The notion of acceptance is very old; philosophers, theologians, and bioethicists have long referred to acceptance in ways that are inexplicit and without coherent logic or practical form. Two of many examples are Aristotle and Bartolome de Las Casas.3,4 The further development and refinement of acceptance, especially as a positively stated good, seem relevant, at least up to the point at which we resolve access issues in the American health care system.
In the discussions within the ACD summits, the ethics consultants recognized that, as valuable as the discussions were, they could not go much further unless a common good was articulated. The "good" could not and should not aim for a code of ethics, but it should describe some of the core values that this new professional interaction was discovering as dentists explored issues such as truth claims in dentistry. What were some of those discovered core values, and who was going to articulate them?
The first core notion was "adequate care." In terms of the bigger picture, the idea of "adequate" or sufficient care was sometimes better than the theoretical "the best." Adequate care could be seen as a practical core notion because systems thinking and its way of identifying boundaries could be used to describe care both in terms of the practical economic limits of today and the theoretical expectations and aspirations for the future. This is an important double step that needs clarification. Systems thinking and its sense of adequate care are on the first step; but the notion of systems ethics was also introduced, and that was another step. Furthermore, systems ethics was introduced in a way that needed to link, rather than separate, theoretical and practical (applied) ethics. More was said about this after another core value (acceptance) arose and was identified.
The second core value uncovered in the ethics summit, then, was acceptance. The concept was frequently articulated, and though I am listing it second, it was and should not necessarily be ranked as second or even ranked at all. It was usually presented unconsciously or off-handedly as a presupposition to many of the conversations. It was, in summary, another important core notion that was discussed along with adequate care.
Defining adequate care and universal acceptance was beyond any one dentist or even any one organization. Describing and adopting a single systems-thinking approach to make the definitions of adequate care and patient acceptance possible were also beyond any one dentist or organization.
This brings us back to systems ethics as a third core notion uncovered in the dental summits. The summit discussions made clear that there was a big difference between individual dentists learning how to ethically think, act, and be and how organizations should think, act, and be. It was a novel idea to most organizational representatives that an organization is just as much a living organism (a "person") as it is a machine.
Each of us participating in the summits needed to interact with people and organizations more as persons than machines. We needed to do this both in our representative organizational roles as individuals and as organizations. That is, there was no obvious way for anyone to put his or her hands on an identifiable consciousness of either the organizations themselves or the systems in which they functioned. Organizations and systems did not seem to have an identifiable moral/ethical consciousness, other than the mission and core values that helped make them something more than a common crowd. It was the individual moral/ethical imaginations of the individuals within the organizations that, through discourse, common agreement, and promises, gave shape to the notion of systems ethics.5–8
Some summit attendees then began to question if all organizations act fully as persons or even ever evolve to the level of being an organism that can truly be called a community. Some groups, however, seemed little more organized than a common crowd. No matter the view, though, all realized that how organizations interact with each other requires still another form of ethics—that is what we call systems ethics. Who would articulate that for the dental profession? As David Smith will discuss in his article elsewhere in this issue, if dentists who knew most about it did not, it would seem weird. Still, who exactly in the profession is responsible? And, better yet, how is it done? The very existence of the summits was already evidence that the action of systems ethics was a real phenomenon. The question then became: if and when an organization articulates a systems ethics for a profession, is it worth our allegiance?
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Bringing Key Collaborators into the Study of Dental Ethics |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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After a brief conversation with Frank, I suggested that what he was talking about deserved more than a one- or two-hour lecture from a few people. I described the efforts of the past summits and the interest in having the next summit focus on the access issue. I also explained why many of the ethics consultants wanted to develop a better ethics framework so that any future conferences on the topic could do some real good. We had oral and written commitments to participate from many organizations, though all of them also commented that up to this point none of their organizations, even the NIH, had specific enough directives to allocate funds in the area of either applied or systems ethics.
Working together, however, Frank and I were able to garner the financial support to hold this workshop. And here we are: a new adventure, with some very skilled people who have also been exploring systems ethics. Ethics as an applied tool in dentistry is still in need of a leading group, perhaps a joint effort by the ADA, the ACD, ADEA, the American Society for Dental Ethics, and Oral Health America. Perhaps it will lead to a philanthropically funded dental ethics center that could actually support the profession and all its systems as they aim to do better. A system that sees acceptance as a common moral promise worth building and acting upon needs to grow out of the world of Adam Smith and yet it also must be something different.5–8
For now, it might be enough to say that when we look at laws, commandments, covenants, or contracts, our conversations can go further when we first look at them as promises rather than rules or obligations. Promises are also worthy of discussion. Promises can be built on both aspirations and cautions, and it is fair to consider both. Professions are a good. And while the basic needs of professions must be dominated by the greater good, professions must also be practical and allow for the less than good. Professions, however, should never prioritize the lesser good over the greater good. This is the premise of this conference; if it is not accepted, then the conference is already a sham. The profession cannot speak for society, but it can speak for itself and we hope to start the conversation.
I believe we have come to a time when we need to go beyond volunteers and individual practitioners supporting this access endeavor and must systematize it as a primary tool to reach for the good. Collins and Poras7 evidenced this reality. It is also key to understanding the effective teaching of ethics in terms of awareness, articulation, motivation, and action that David Ozar has discussed in seminars but not yet published. The ability of an individual to articulate an ethical issue is as important as an organization’s ability to make a mission statement based on discovered core values. It is a primary component of making promises. Focusing on ethics statements is the best bang for the buck in applied ethics work. It is too important to leave only to those independent practices and organizational management companies that do it on their terms, with only a few days of input from a few members, and for profit. Members of the profession, the profession itself, must be actively and continuously involved. We must encourage conversations within the entire profession so that greater ethics and organizational systematization will move us beyond volunteerism, which so limits ways by which we address access to health care.
David Chambers and Shafik Dharamsi discuss some of the systematization presuppositions in their articulation of discourse ethics, elsewhere in this issue. Perhaps, in time, acceptance can be taken far enough to make it the key to developing a systems approach to all the forms of discourse in which we participate that aim to better our ability to handle everyone’s desires. For now, however, discourse itself is not yet or is perhaps no longer integrated into a coherent community system. We still like to keep separate the discourses of science, politics, philosophy, and narratives. Furthermore, each of these discourses has subgroups that also remain separate because of their special skills and knowledge. Yet, we still try to come together to talk. A very relevant addition, for our purposes here, is that when it comes to religious discourse, separation takes on a new meaning. Without it, some will be hard pressed to find ways to bring passion to their moral reasoning.
Earlier I described a way to separate how doctors and patients talk about their desires and how people become patients. The steps were acceptance, diagnosis, treatment, and payment. In a sense, those same steps could be applied here. It should be no surprise, though, that each of these steps often has distinct political, philosophical, and scientific discourses and actions. They work well when thought of as a single step, but the reasoning they use often breaks down when carried to another step or applied to the entire process.
Talk about acceptance will gain strength in a discourse that acknowledges egalitarian philosophy, whereas talk about payment, in the United States at least, will need a respect for the contributions of libertarian philosophy. Yet, it doesn’t need to be that way. The real wonder is why things still seem to work out without these philosophical and ethical acknowledgments and respects. Brian O’Toole introduces a tool that will help us experience why that is; Alasdair MacIntyre also thinks we can do better with all these discourses; so do I and many others.1,5,7 Acceptance may not be the guiding star or the perfect way; for now, however, it may only be a better way, and then on to the next step.
This is a rare moment. What are some real promises each of us can make to better oral health care for all?
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To Whom Will We Promise Our Allegiance? |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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On the contrary, spouses’ characteristics are selected before they are accepted as partners. With time, parents learn to love their children’s less desirable characteristics; spouses can part, however, as they learn of their partner’s undesirable characteristics that went unnoticed earlier.
A third notion of acceptance was, and still is, expressed by the reasoning of those who took, and still take, religious chastity vows. They promise not to love any one person more than others so they can love all equally, as God does. By accepting no one, they accept all. Attentiveness to this universal form of acceptance of others expresses a desire to nurture an authentic sympathy that is not the same as the familiar detached concern or equanimity for all that permeates the teachings of William Osler, founder of modern medicine.
In terms of health care, then, the role of acceptance is already at play. The promise of what is meant by acceptance is as valid today as in 350 B.C. or 1900. Some find it worth thinking about the nature of doctor-patient relationships by comparing them to 1) spousal promises, 2) natural parental relationships, and 3) vocational relationship vows. Are there other kinds of relationships? Which should be prioritized and when?
Bartolome de Las Casas asked similar questions about acceptance—not of patients, but of persons as citizens. Las Casas came to America ten years after Columbus landed and worked with the American Indians. He learned their language and culture and reported on it for more than fifty years. As he became aware of their non-acceptance as citizens, he also discovered the power it was holding over them. He began to argue with popes, kings, philosophers, and theologians to get the American Indians (Indian, from "In Dios" or "of God") accepted as people.
His discussions are only just being rediscovered, not only for their integrity, but also for their influence on the sixteenth-century philosophers who formed much of the thought foundation of the Great American Experiment. In short, he questioned if the empires of Europe truly were interested in bringing God to the only people on earth who were never exposed to the Judeo-Christian notion of acceptance by God.9
Was it the pragmatics of gold or the promise of God that dominated? In his religious and philosophical discourses, Las Casas argued much about the loss of Columbus’s dream. His lament, throughout his last sixty years, was that the greater good was obscured by the glitter of gold.4 There was little desire to accept acceptance. As we come together this weekend and expand our continuing education of professional ethics in dentistry,10 let us not let ideas, numbers, and gold outweigh people and their care.
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Footnotes |
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REFERENCES |
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TopAbstractPreventive dentistry research...An insurance crisis, acceptance...The continuing education of...Core dental ethics summit...Bringing key collaborators into...To whom will we...References |
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This article has been cited by other articles:
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  S. Dharamsi, D. D. Pratt, and M. I. MacEntee How Dentists Account for Social Responsibility: Economic Imperatives and Professional Obligations J Dent Educ., December 1, 2007; 71(12): 1583 - 1592. [Abstract] [Full Text] [PDF]
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D. E. Patthoff The Need for Dental Ethicists and the Promise of Universal Patient Acceptance: Response to Richard Masella's "Renewing Professionalism in Dental Education" J Dent Educ., February 1, 2007; 71(2): 222 - 226. [Abstract] [Full Text] [PDF]
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P. H. Werhane Access, Responsibility, and Funding: A Systems Thinking Approach to Universal Access to Oral Health. J Dent Educ., November 1, 2006; 70(11): 1184 - 1195. [Abstract] [Full Text] [PDF]
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