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Band-Aid Solutions to Problems of Access: Their Origins and Limits

Key words: profession, justice, access to services

	Abstract

Top Abstract Professions Public power and justice The dental profession and... Reference

 
Many persons lack adequate access to oral health services. The causes of this are a constricted understanding of the roles of governments and professions. Both those groups have responsibilities to ensure that a decent level of oral health care is available to all persons in the United States. If the dental professions as a whole were to embrace this ideal, the sacrifices required of any one professional would be minimal.

Our health care system is the result of political and philosophical compromises. In itself this is no bad thing. Compromise is not a dirty word, and it is natural to want to honor all our values. Indeed, my own preference is for pragmatic working out of mechanisms of provision rather than for a strictly logical system. But when a set of social arrangements doesn’t work, and it’s pretty clear this "system" isn’t working, then it is time seriously to consider what changes might be made and who should make them. Here are the reasons I think the system isn’t working:

• Too many people are not getting adequate dental care; they are often poor and powerless. For example, according to Oral Health in America: A Report of the Surgeon General—Executive Summary, a third of Americans have no access to fluoridated water, 108 million children lack dental insurance, and poor children have twice as many dental caries as their better-off peers. More than 51 million school hours are lost annually to oral ill health. This is twelve times as likely to occur among the poor.¹
  
• Under the current arrangements, the burden of caring for the poor falls disproportionately on a few members of the profession. They make considerable sacrifice in terms of working conditions, lifestyle, and income in order to act according to their principles. But many, perhaps most, dentists do nothing. They provide minimal levels of pro bono care and seldom if ever volunteer to serve in free clinics. We have too few heroes and too many free riders.
  
• Moreover, careers have trajectories over time. Some conscientious dentists who are aware of the problem of providing dental care for the poor are at a point in their lives at which the price of altruistic professional work seems too high to them. Perhaps they once made major sacrifices, but then they burned out. People of good will only make major sacrifices for a limited period of time. "Once burned, their fault; twice burned, my fault," they may say. The result may be that many professionals of all ages live with a bad conscience or become cynical. No one seriously disputes that U.S. society in general, and the dental profession in particular, has the resources to make major improvements in the situation. What is lacking is the will, along with an adequate understanding of the problem. Why are we in this situation?
  

I think there have been three key mistakes. We operate with an impoverished view of what it means to be a profession, and our conception of the legitimate powers and essential role of government is too ideological and narrow. Therefore, third, we fall victim to dichotomous thinking: either public or private provision. The reality is that modern dental education and practice are both public and private, and both government and the dental profession have key roles in improving the situation.

	Professions

Top Abstract Professions Public power and justice The dental profession and... Reference

 
Too often we think of professions as just jobs: things people do in order to make a living. But that is not what they started out to be or what they are at their best, because the word "profession" should connote an identification of the self with the work. A professional is precisely not someone who just puts in his time; he is someone who is personally invested in the quality of the work. Think of the etymology of the word "profession." It relates to something one professes or stands for. Good professionals are inevitably a little weird because they care about something—the mouth, or hitting a baseball, or the rhythm and pitch of an orchestral concert—more than other people do. They are unusually knowledgeable, and they care if they are true professionals.

I don’t mean to say that professionals are necessarily tactless or that they shouldn’t value leisure, income, families, and other goods of life. Something’s wrong with them if they don’t. But the relationship between a professional and his or her work is distinctive: it is absorbing, and it is hard for the engaged professional to put it down or let it go. I’d contend that this distinctive attitude toward work defines what it means to be a professional better than a focus on the traditional "professions" does. Artists, engineers, and journalists can be professionals in this sense, every bit as much as members of the traditional professions of law, medicine, and ministry.

But education of professionals, such as dentists, should aspire to produce graduates who will become professionals in the sense of selves who are engaged with their work. Americans want professionals to be persons for whom, to a significant degree, the work is its own reward. That this is idealistic I freely concede; that it is therefore irrelevant I staunchly deny.

The relevance of this fact to my argument is simple. Assuming that professionals want to be persons of integrity, what they stand for in ethics and politics should have some relationship to the foundational commitments and experience of their work. Their politics should reflect their professional commitments and learning, not just their economic self-interest. We rightly expect professionals to play a kind of representative function. We want dentists to tell us what good oral health requires of us, to tell the community what it needs to do to improve the oral health of citizens, and to act and vote to accomplish those things. We don’t expect dentists to starve or fail to make a good living; we do expect the profession to stand for more than collective self-interest.

Dentists should care about oral ill health whenever and among whomever it may appear. Caring should be reflected in the dentists’ public and professional actions. The real question for a serious dentist is not whether to do something but what to do.

	Public Power and Justice

Top Abstract Professions Public power and justice The dental profession and... Reference

 
Our second mistake is lazily imagining that we can rely on the goodwill of a few professionally responsible dentists to solve our problems of inadequate access to dental care and the means of securing oral health. We are reluctant to admit that adequate provision may require the use of power and that, to ensure care for all, some may have to do what they would not prefer—pay more taxes or work one half-day a week in a free clinic.

Charity provision seems to us to be virtuous, whereas thinking of health care as a matter of right—of justice—seems troubling. We are not wrong to commend and support the provision of care through individual choice, charity, and love. The world would be a poorer place without it, but it is insufficient to meet the needs of the poor. Why? Because human beings are affected by what the theologians like to call sin: by insecurities that cannot be acknowledged that lead to concern for self, self-righteousness, and inability to see the limits of one’s own perspective. Our actions are not solely self-interested, but self-absorption alters our perceptions and twists our behavior in ways that we often are unaware of.

The poor are not angels; they are no more perfect in motivation and freedom from the power of anxiety than anyone is. But there is one difference: they don’t have power. If they are to have a chance at a decent life, government must take their side against economic and political vested interests. Health care is no more an exception to this rule than is education. Perhaps there were societies in which basic health care and education—as those societies understood them—were not seen as basic needs. But that is not our society. It is entirely hypocritical to cherish those goods for ourselves and not recognize some level of obligation to make sure they are accessible to our fellow citizens. Justice requires no less.

One cannot dodge the force of this argument by stressing the importance of good personal oral hygiene. Much oral ill health is not the fault of the patient in any morally serious sense of the word "fault," any more than lack of coordination or mental slowness are the faults of some children themselves. Individuals do have responsibility for their own health, but the genetic and social lotteries distribute remarkably inequitably the power to do something about the hand of health cards we have been dealt. Booker T. Washington was onto something important when he stressed the "gospel of the toothbrush." We respect people who work hard to improve their lot in life, but it takes extraordinary insight to be able to discern whose success is the result of hard work and whose is simply a matter of dumb luck.

Thus, given our limited insight, the random nature of many dental problems, and the importance of oral health, we rightly expect government to take responsibility for assisting in the provision of dental care to all citizens.

	The Dental Profession and Social Justice

Top Abstract Professions Public power and justice The dental profession and... Reference

 
If professions are groups of people who profess that they have an obligation to help individuals and promote the common good, and the government is an entity with responsibility to ensure meeting of basic needs, then the way beyond an incoherent "system" is to acknowledge the social responsibility of the dental profession to work with government at local, state, and federal levels to ensure that all persons who need treatment for dental problems have access to it. This alliance is not weird. Government funding for health care provision of all forms is much greater than is usually acknowledged. Tax dollars heavily subsidize the education of dentists, and a variety of federal, state, and local programs provide some levels of care for the poor. Few private or nonprofit entities operate independently of any and all forms of public assistance.

There are at least three ways in which this alliance might work. In the first, one or the other party denies its responsibility. For example, the dental profession might, in effect, say that care for the poor was not its responsibility. Governments or churches or some other entities should come up with the dollars needed to include the needy in the regular fee-for-service system. Alternatively, the government could say that it was really not in the business of providing welfare. Therefore, ensuring adequate care would be the responsibility of charity or of professionals through pro bono work. We have lived with this schizoid mentality for decades with all the bad consequences for service provision, professional morale, and self-respect that I tried to identify at the beginning. This is not an alliance, but a denial of the legitimacy of participation by one’s own organization or other players. It’s a nonstarter.

Second, and more interestingly, we might argue that there are two separate but coequal responsible partners. Dentists will provide the care; government will provide the money. Dentists don’t enter the political arena, and bureaucrats don’t mess around with the details of dental practice. Each party has a right to fault the other for letting the other down: by providing too little money to ensure provision of care, or by failing to provide quality care. What each party expects from the other is more and better of what the other party is expected to do.

This solution to our problem is attractive in many ways. It is logically and psychologically clean. Dentists don’t need to get into discussions about provision for the poor; government can leave the dental profession alone. If both sides did their part, we’d be in great shape. But there are some serious problems, beginning with the impossibility of the arrangement. If government funds are to be used to provide dental care, it is a simple matter of public responsibility that government must ensure that the funds are well spent. The public purse cannot give anyone, even dedicated professionals, a blank check any more than a private entrepreneur can. And conversely, public administration doesn’t know what is needed unless the dental profession tells it. Furthermore, even if these two forms of power—power of the purse and law, and the power of knowledge and experience—could be kept in watertight compartments, it would be undesirable, for it would lead to much wasted expenditure and a failure by dentists to take the kind of leadership responsibility that they can and should take.

Consequently, thirdly, I think that the teaching and representative functions of the dental profession that I mentioned at the beginning should come to the fore in the alliance. The key to this will be a significant level of solidarity in the dental profession. The profession must make the nature of our problems with oral health clear to the general public and suggest both what it is prepared to do about them and what forms of public support it needs to be able to provide the needed services. This will be most effectively done if the profession is prepared to make some commitments on the part of its members and to call upon its members to make some level of sacrifice.

The political keys are transparency and sacrifice for the sake of the commitment. The first public reaction will be "What do they want to get out of this?" and the answer has to be: a clear conscience and sense that we have put ourselves on the line for what we believe in. And the sacrifice has to be shared. If it is distributed over a large number of professionals, it will not be particularly onerous; but if it is like volunteering to do the dishes after the church supper, it will place an impossible burden on a few.

That is why I say solidarity is essential. It can come about in two ways. First, the government could require that all dentists perform some level of professional service as a condition of licensure. This period of service could be intensive for a year, spread out over a decade, done immediately after graduation, or postponed until sometime in mid-career. The work would not be freely chosen, but it would dramatically increase the amount of time dentists commit to serve the poor and uninsured.

This strategy is certainly not optimal, because the public service would be regarded as a prison term to be served. The care would be provided grudgingly and would be unusually uneven in quality. That’s why I’d prefer that the profession take the lead and make some commitments that it requires dentists to live up to. Some participants will go kicking and screaming; political prices will be paid by leaders of the profession. But if the program is sponsored by leaders of the profession and treated as if it is the essence of what it means to be a professional, it will go much better than if it is imposed from without.

The chronic inadequacy of our provision of oral health care raises issues in our understanding of what it means to be a professional and of what we should expect from government. If we are to improve on this situation, political and professional leadership is called for. I’ve recommended an idealistic path for the dental profession—something easy for a non-dentist to do. But moral life isn’t easy; and as all hardworking professionals know, the greatest gratifications follow willingness to make some changes and sacrifices.

	Footnotes

 
Dr. Smith is the Robert and Carolyn Frederick Distinguished Visiting Professor of Ethics, Department of Philosophy, DePauw University. Direct correspondence and requests for reprints to him at Poynter Center, 618 E. Third Street, Bloomington, IN 47405; 812-855-4539 phone; 812-855-3315 fax; smithd{at}indiana.edu.

	REFERENCE

Top Abstract Professions Public power and justice The dental profession and... Reference

 

1. Oral health in America: a report of the surgeon general—executive summary. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

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