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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Key words: universal access, oral health care, systems thinking, moral imagination
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Abstract |
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Justifications for Universal Access to Oral Health Care |
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TopAbstractJustifications for universal...Systems thinkingSystems thinking, boundary...The "so what?": universal...ConclusionReferences |
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Rights Talk and Entitlements
Rights talk is grounded on a set of assumptions that human beings have intrinsic value, that is, that they are of value just because they are human beings, regardless of their particular historical, religious, or cultural roots or physical or mental abilities. Moreover, "every conception of human rights—by which I understand fundamental rights every human being can claim as a human being—presupposes . . . a conception of the moral person who is the author and addressee of such claims."1 Human rights are usually referred to as moral rights, because they are inviolable claims to which every human being is entitled, and entitled equally, but they are not always honored as such. Beginning with the seventeenth-century philosopher John Locke,2 a number of philosophers have argued that these basic rights include rights to life, to survival, to liberty, and to property.2–5 Linked to all rights claims are obligations. That is, if the notion of universal rights makes sense, then each of us, as rights claimants, has concomitant obligations or responsibilities to respect, and respect equally, the equal rights of others.5,6 These rights are carefully stated in the United States’ Bill of Rights and in the United Nations’ Universal Declaration of Human Rights as ideals to which every individual, institution, and nation should strive. If these declarations have any weight and are to be guaranteed by our Constitution and Bill of Rights, it would follow that rights to universal health and thus equal access to health care and oral health care by which we can better survive and enjoy our liberties should also be guaranteed. But in health care and oral health care, they are not.
Rights are sometimes confused with entitlements. An entitlement is something to which one has a claim whether or not one has obligations to other claimants, and entitlements are ordinarily culturally, ethnically, politically, or gender-based. As Americans, we usually say that each of us, as U.S. citizens, is entitled to vote whether or not we have extended or guaranteed that entitlement to others, for example, permanent foreign residents. So sometimes it is argued that, as human beings, or more restrictively as Americans in one of the richest countries in the world, health care and oral health care are entitlements that each of us should have, whether or not we have concomitant responsibilities to contribute to its realization or payment. Rights claims are somewhat different: they are universal claims that entail obligations to respect and even, in certain cases, enable the realization of others’ claims, or at least not hinder those attempts.6
Professional and Organizational Obligations
A second set of arguments defending universal access to oral health care derives from the definition of a health care professional and oral health delivery systems. Oral health care professionals and health care providers claim they are in the profession or business of oral health. It follows that the primary aim of oral health care treatment and delivery is, or should be, according to the precepts and definition of the profession and providers, to deliver effective and efficient care while respecting patient dignity and autonomy. To limit access of indigent people who need oral health care seems on the face of it contrary to the mission of oral health professionals and providers. Moreover, according to professional codes of ethics, oral health professionals have obligations to serve communities as well as to provide care to their patients. At a minimum, those indigent patients who demand care should receive it. As a professional, can one turn down such demands? According to arguments by Donald Patthoff7 and others, as a professional in a community one cannot.
Similarly, those in the business of oral health, e.g., pharmaceutical companies, manufacturers, etc., are creating and selling products and services aimed at health and alleviating disease. Because they are, by definition, in the health business, can they ignore indigent consumers?8
Distributive Justice
Third, precepts of distributive justice question the inequalities in health care and oral health care delivery in our society. Currently, the ability to be insured or pay governs access. That cannot be fair. Those on Medicaid and those who are uninsured or poorly insured do not get the same quality care as those of us with financial resources and good insurance. There are groups of people who, because of financial circumstances, are below any reasonable assessment of a decent health minimum. At least 10 percent of all Americans have never seen a dentist, or only seen one when that person was in dire pain or subject to infection. Poor oral health affects one’s general health and puts those people at a disadvantage in getting and keeping jobs and in trying to live a decent life. Thus the lack of health and oral health care accessibility creates needless inequalities, many of which could be rectified simply with preventive care.9
Challenges
All these arguments in defense of universal access, and there are many others, unfortunately, have been reiterated many times by professionals and professional societies, by politicians, and by ordinary citizens. There are strong counterarguments as well. First, the cost of universal access promises to be astronomical. Who is responsible for providing this; who should bear that burden? Is this only a local, state, and national government responsibility as some would intimate? What about the responsibilities of professionals and professional associations to take on indigent patients and provide oral health care to this class of individuals? Should insurers and providers bear some of these costs as well? Providers often do, by taking on a limited number of indigent patients each year. Should they have to do more? What about philanthropic organizations? Should they give less to the opera and symphony and more to providing oral health care to those who cannot afford it? Finally, what about patients, the consumers of oral health care? Should those who are financially able pay more for oral health delivery? Should oral health care be provided only to those who demand it, or only to those indigent who seek care? Or should there be universal access to everyone in our society as an entitlement?
I have presented these challenges primarily as either-or scenarios. But that is wrong-headed and oversimplified. Our present health care system in the United States, and thus our present oral health care system, is in fact a complex messy set of systems with many interrelated and noninterrelated subsystems. Figures 1
and 2 illustrate the complexities and shortfalls of the present system. Thus looking at issues around universal access linearly or as either-or choices belies the complexity of the system and its problems.
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Systems Thinking |
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What is characteristic of all types of systems is that any phenomenon or set of phenomena that are defined as a system has properties or characteristics that are lost or, at best, obscured when the system is broken up into components. For example, in studying oral health, if one focuses simply on patient-professional relationships, one neglects to take into account the interconnections and interrelationships that characterize that system or subsystem. In oral health we have to consider oral health professionals, insurers both private and governmental, manufacturers, clinics and other delivery systems, laboratories, teaching institutions, social workers, patients, would-be patients, and the community, all of which are embedded in a political economy with a vast array of political agendas, each with its own interests. All of these components affect oral health payment, delivery, and access. The kinds of systems I am concentrating on in this article have another characteristic. Each type of system or subsystem is what the Institute of Medicine calls a "complex adaptive system" that is purposive or goal-oriented.14 In oral health the primary purposes are disease prevention, patient care and well-being, and respect for patient autonomy and dignity.
The goal orientation of any system accounts for its normative dimensions. As has been argued extensively elsewhere, organizations as well as individuals have purposes and goals that carry with them moral obligations, and we hold organizations and institutions, as well as individuals, morally accountable.4,15 While it is less transparent that systems are moral agents of some sort, it is true that the structure, interrelationships, and goals of a particular system produce outcomes that have normative consequences. An alteration of a particular system or parts of that system will often produce different kinds of outcomes. Universal coverage for oral health, for example, would change dramatically patient load, supply of oral health professionals, teaching institution admittances, delivery and manufacturing systems, etc., just as managed care changed our health care delivery system16 and, as a result, changed our expectations as well.
How the system is construed—how it operates—affects and is affected by those of us who come in contact with the system, whether we are individuals, the community, professionals, companies, or government agencies. Thus, moral responsibility is incurred by the nature and characteristics of the system in question. In health care we blame the government for not providing universal access; we blame professionals for not extending their charity care; and we even blame the jobless for being unemployed and the working poor for being uninsured. We blame politicians and government for our country’s endemic poverty, yet at the same time we often conclude that "there is nothing they can do about it."
Systemic arrangements and networks create roles and role responsibilities, rights, and opportunities that affect individuals and individual activities and performance. What is less obvious is that one can take a single organization or a single individual functioning within that organization or system and apply different systems matrices to that organization with differing outcomes. What subsystems and individuals functioning within these systems focus on and the ways values and stakeholders are prioritized affect the goals, procedures, and outcomes of the system or subsystem in question. On every level, the way we frame the goals, the procedures, and what networks we take into account makes a difference in what we discover and what we neglect. These framing mechanisms will turn out to be important normative influences on systems and systems thinking, and thus on how we think about distributing or redistributing oral health care access.
What do we mean by "systems thinking"? For our purposes, systems thinking presupposes that most of our thinking, experiencing, practices, and institutions are interrelated and interconnected. Almost everything we can experience or think about is in a network of interrelationships such that each element of a particular set of interrelationships affects the other components of that set and the system itself, and almost no phenomenon can be studied in isolation from all relationships with at least some other phenomenon. In a systems approach, "concentration is on the analysis and design of the whole, as distinct from . . . the components or parts."17 Systems thinking requires conceiving of the system as a whole with interdependent elements, subsystems, and networks of relationships and patterns of interaction. Studying a particular component of a system or a particular relationship is valuable only if one recognizes that that study is an abstraction from a more systemic consideration. Few systems are merely linear, and few, including oral health care systems, are closed systems that are not constantly in dynamic processes of changing and reinventing themselves.14 Therefore, systems thinking involves multiple-perspective analyses of any subject matter. Because "the fundamental notion of interconnectedness or nonseparability forms the basis of what has come to be known as the Systems Approach, . . . every problem humans face is complicated [and] must be perceived as such."18 So each system or subsystem, because it is complex and entails a multitude of various individual, empirical, social, and political relationships, needs to be analyzed from multiple perspectives. In examining ethical issues in health care systems, subsystems, and organizations, a multiple perspectives approach requires developing an overlapping set of two grids, the elements of which I shall initially label descriptive and normative. We shall see, however, that these are provisional labels, because the two elements overlap considerably.
The first, a descriptive or "technical" approach, includes the following. First, one describes the health care system in question from a sociological point of view. Included in the description are networks of interrelationships between various stakeholders, that is, those individuals, groups, organizations, and systems that affect or are affected by each other and the system in question.19 (See Figure 3.) For example, in oral health one needs to outline professional and clinical obligations, the role of regulation, payer options (e.g., insurance and Medicaid), how manufacturers and delivery systems influence oral medical care and financial costs, present access possibilities for the uninsured, professional education, and the financial pressures on young interns and dentists.
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From the perspective of insurers, often the focus on price and efficiency overrides considerations of providing for the costs of effective care. In these instances, the quality of care and for whom it is provided are sometimes prioritized as secondary, thus marginalizing those issues or the uninsured at the boundary of consideration. From the perspective of distributive justice as we have outlined it, the boundary conditions should be broadened to include all those in need of oral health care—quite a different point of view. All of these considerations illustrate how disparate prioritizations of stakeholders and values alignment (including economic values) change the perception of boundary conditions and affect decision making.
Linked to the boundary conditions and stakeholder values prioritization are accountability relationships between each stakeholder in the system in question. It is tempting to conceive of those dyadically, and from a professional approach a dyadic description of accountability may seem to be adequate. That is, as a professional, I may focus primarily on my patients. But today professionals depend on private insurers and Medicaid/Medicare for payment; they are heavily regulated and government is often the price-setter; and there are enormous demands to expand care options in their communities. So oral health care professionals are imbedded in and affected by a very complex system, and these relationships are much more overlapping and interlocking than a simple dyadic relationship suggests. Figure 3
is a partial graphic depiction of some of these accountability relationships. Being clear about these relationships, and how each individual element of the system is or should be accountable to each other, helps to clarify where decisions go wrong.
As a patient I am primarily interested in my oral health needs and care. But I too am responsible for finding good providers, seeing to it that I am insured or have other means to finance my care. And I am part of a community and a taxpayer who is negatively affected when others are ill or otherwise disabled due to lack of proper health care.
Normatively, one needs to determine what goals or purposes the system has, or what goals it should have, and how these are prioritized, since the goals a system has will affect its structure and interrelationships. These prioritized goals then become the evaluative elements overlaid on the descriptive grid. Elsewhere, a number of people including David Ozar, Linda Emanuel, Ann Mills, Ed Spencer, Mary Rorty, Jessica Berg, myself, and others, laid out and defended a scheme for values prioritization in health care that sets out the purposes that health care, and thus oral health care, espouses or, we have argued, should espouse.16,22,23 Our basic argument was that if a professional, organization, or governmental body claims to be in health care, whether as an insurer, manufacturer, professional, clinic, social worker, public policymaker, or whatever, by definition of what one claims to do, one’s primary obligation is to the health and autonomy of one’s patients or groups of patients. (See Figure 4.) Second, professional excellence is critical if one is to provide oral health. Third, public health has to be a priority no matter how one comes out about universal coverage, if for no other reason than to protect the health of the rest of us. Originally, we prioritized financial viability as a fourth priority. Our thinking was that if professionals, manufacturers, and clinics are not fiscally viable, they will close. We were agnostic about whether a health care organization should be a for-profit organization, but we recognized that oral health professionals need to make a living and the other related health care organizations needed at least not to go into bankruptcy. Today, I would reorder these priorities and place universal access to health care and oral health care as the third priority and as part of public health’s responsibilities. The descriptive grid imports normative/evaluative components in evaluating the shortcomings of the boundary perceptions, accountability relationships, and goal prioritization. But there are other elements a normative dimension introduces as well.
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Systems Thinking, Boundary Conditions, and Moral Imagination |
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Mental models might be hypothetical constructs of the experience in question or scientific theories; they might be schema that frame the experience, through which individuals process information, conduct experiments, and formulate theories. Mental models function as selective mechanisms and filters for dealing with experience. In focusing, framing, organizing, and ordering what we experience, mental models bracket and leave out data, and emotional and motivational foci taint or color experience. Nevertheless, because schema we employ are socially learned and altered through religion, socialization, culture, educational upbringing, and other experiences, they are shared ways of perceiving, organizing, and learning.
Because of the variety and diversity of mental models, none is complete, and "there are multiple possible framings of any given situation."28 By that, we mean that each of us can frame any situation, event, or phenomenon in more than one way and that same phenomenon can also be socially constructed in a variety of ways. It will turn out that the way one frames a situation is critical to its outcome, because "there are . . . different moral consequences depending on the way we frame the situation."23,27,28
Mental models, as Peter Senge carefully reminds us,24 function on the organizational and systemic levels as well as in individual cognition. A multiple perspectives approach takes into account the fact that each of us individually, or as groups, organizations, or systems, creates and frames the world through a series of mental models, each of which, by itself, is incomplete. While it is probably never possible to take account of all the networks of relationships involved in a particular system, and surely never so given that these systems interact over time, still, a multiple perspectives approach forces us to think more broadly and to look at particular systems or problems from different points of view. This is crucial in trying to address access issues, because each perspective usually "reveals insights . . . that are not obtainable in principle from others."18 It is also invaluable in trying to understand other points of view, even if eventually one disagrees or agrees to disagree.
Moral Imagination
Often we are trapped within a framework of thinking that creates mental habits that function as boundary conditions, precluding creative thinking. To change or break out of a particular mindset requires, as Moberg, Seabright,29 and I27 have argued, an operative moral imagination. Moral imagination is "the ability in particular circumstances to discover and evaluate possibilities not merely determined by that circumstance, or limited by its operative mental models, or merely framed by a set of rules or rule-governed concerns."27 Moberg and Seabright define moral imagination as "a reasoning process thought to counter the organizational factors that corrupt ethical judgment."29
How does moral imagination function? On the individual level, being morally imaginative includes:
But how do we do all of that while at the same time taking into account situational peculiarities, social context, and the systems in which we are embedded? How do we act in a morally reasonable manner and trigger moral imagination? More importantly for this article, how does moral imagination work on all dimensions in our oral health care system?
A good example of this process in practice is the visionary work of the American College of Dentists. Some years ago they convened (and continue to convene) a diverse group of important stakeholders concerned with oral health. These included, of course, oral health professionals including dentists and technicians, social workers, representatives from government providers (e.g., military oral health professionals) and from Medicaid, private insurers, pharmaceutical representatives, manufacturers, educators, and representatives from clinics and other provider organizations. Top-level people from each of these sectors attended the first two conferences. The first goal was to establish value priorities on which all participants could agree. It turned out that whether one was in the for-profit pharmaceutical business or a military dentist, the first priority upon which all could agree was patient oral health and care in addressing disease.23 Discussions are ongoing about financing, pricing, regulation, profitability (or not), access for the indigent, levels of service, and other issues about which there is not, and may never be, consensus. It is difficult, at best, to pinpoint every individual involved in initiating this change, and not every stakeholder continues to participate in the dialogue. But at least one subset of oral health professionals changed and are continuing to change their and other mindsets and use a great deal of moral imagination to push forward to develop strong interrelationships in the oral health arena—relationships that were, and some still are, at best, arms-length.
Moral imagination is not merely a useful term to describe individual decision making in a dyadic setting. It also can and should involve a systemic multiple perspectives approach. This includes the following:
In this process, one needs to describe the system and its networks of interrelationships to grasp the interconnectedness of the system. One needs to investigate what is not included in the system (its boundaries and boundary-creating activities) and what mindsets are predominant, asking who are the stakeholders (individual patients and potential patients; oral health professionals and professional associations; delivery organizations; agencies; local, state, and national government interactions; regulations and funding) and what are the core values of each set of stakeholders. Additionally, one needs to outline the core values of the system and speculate as to what these should be. Finally, one should think about whether and which organizations or individuals within the system might be capable and willing to risk challenging bits of the system and carry out change. The result is that moral imagination and systems thinking encourage networked systems analysis that is engaged and critical, creative and evaluative, and values-grounded and that encourages constructive change within a network of relationships.
There is one more consideration: that of individual responsibility, the responsibilities of each of us as politicians, managers and executives, professionals, insurers, patients, and individual citizens. A systems approach should not be confused with some form of abdication of individual responsibility. As individuals we are not merely the sum of, or identified with, these relationships and roles; we can evaluate and change our relationships, roles, and role obligations, and we are thus responsible for them. That is, each of us is at once a byproduct of, character in, and author of our own experiences. So each of us is responsible for examining, evaluating, critiquing, and finding means to change organizations and systems in which we find ourselves.
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The "So What?": Universal Access Revisited |
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It is tempting to argue that we should have a single-payer health care system funded by local, state, and national governments. But even if that is a politically viable choice, many argue that it is too expensive and that health care and oral health care will become mired in even more bureaucracy than is evidenced today with Medicaid and Medicare. Others defend the present market-driven system as the "least worst," particularly if it could be coupled with an expansion of patient choice.30 Others argue that oral health professionals and professional associations should take on more of the burden of pro bono work and/or that philanthropic organizations should bear most of the burden of funding indigent patients. But in a society with a moderate scarcity of funds and a limited number of oral health professionals, there are financial and professional limits to this option as well.
Looking at this morass of possibilities from a systems perspective, it is more propitious to take a multilevel approach—that is, to argue that all of us, paying patients, insurers, manufacturers and pharmaceuticals, professionals and their associations, and governments, as citizens in communities and as professionals and companies that benefit from health care markets, bear some of the responsibility. We all have obligations. State and national governments should take on revisions of public policy and work on universal funding for the uninsured, a proposal that is being tested in Massachusetts.31 Private insurers, too, could form large group insurance programs for the indigent, and some are working on this now. But none of these options is a singular unlimited obligation. The tiered patient-choice option for many selective service government employees offers health care without undue fiscal burdens. That model should be copied in providing Medicare and Medicaid and for expanding the coverage to the uninsured. At the same time, every person at whatever income level should pay something for their care, even a dollar. This is because in this society we value goods and services that cost money; whether or not this is a good way to value, I shall leave to others to decide. But the truth is that, if it is free, we often neglect or do not value that good or service, creating what Garret Hardin once called the "Tragedy of the Commons."32 Oral health professionals and professional associations should contribute some pro bono care, but better distributed among all professionals, not merely those who take on these patients voluntarily. Manufacturers and pharmaceuticals need a tiered pricing system, so that those who cannot pay "full price" (I shall avoid discussing how one should define "full price," but recognize it is, at best, a contentious proposition) are still able to get needed drugs and appliances. Insurers have responsibility to create tiered group policies that target the less able as well as those of us who are well insured. Wal-Mart’s new attempt to offer low-cost health insurance to their low-wage workers will provide some competition in that arena.33 Philanthropic organizations bear responsibility as well, but many are now overextended, particularly those that contribute to not-for-profit health care educational and delivery organizations. Finally, those of us who are fiscally able bear some responsibility as well: to increase our copays and to restore autonomy and fiscal responsibility to ourselves for the oral health care we receive. If each individual, organization, and profession reconsidered their either/or mindsets and thought of access to oral health care as a function of a series of public-private partnerships with the shared value of improving oral health, we might make progress in improving our health care system (Figure 5).
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Conclusion |
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Footnotes |
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REFERENCES |
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This article has been cited by other articles:
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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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D. T. Ozar Applying Systems Thinking to Oral Health Care: Commentary on Dr. Patricia H. Werhane's Article. J Dent Educ., November 1, 2006; 70(11): 1196 - 1197. [Full Text] [PDF]
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