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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
One of Dr. Patricia H. Werhane’s assigned tasks was to formulate the several other current approaches to the ethics of access that were not discussed in my "Ethics, Access, and Care,"1 and her survey of these other approaches is very useful. But what is most important about Werhane’s article2 is her powerful argument that any solutions to the problem of inadequate access will have to be systems solutions. The reason is that the causes of the gaps in people’s access to oral health care are systems problems. Thus, Werhane is absolutely correct in urging that, to address the issue of access to oral health care effectively, we must engage in systems thinking. Anyone who cares about this issue owes a debt to Werhane for explaining in such clear terms what systems thinking requires and in identifying the activities of moral imagination that are crucial to thinking in this way.
I will not try to repeat Werhane’s points about who the players are or how thoroughly we need to understand their respective roles and interrelationships if we hope to produce effective proposals about access to oral health care. She has stated all of that very well. I shall focus my commentary instead on two possible reactions to her article and then on a teaching point.
One might react to Werhane’s article negatively, not rejecting its lessons but despairing of having any impact on a problem so complex and so entrenched in so many powerful and interconnected institutions. It can be pretty depressing to look honestly at how complex this issue really is, and Werhane’s account of players and relationships could hardly portray a more complex picture. So one might be tempted to say: we will never get all of these players to agree on anything, much less to actively coordinate what they do to be responsive to what the other players do!
But another reaction is the one I recommend. It is to get on with it! For Werhane’s first lesson is that this is what it is going to take, and therefore we need to start now to take her advice. Obviously this will not be easy. Changing our mental models is never easy. But if we believe that unmet oral health needs really are a pressing ethical issue, that is where we have to start.
We need to begin doing systems thinking about access to oral health care much more carefully and in much more detail that anyone has done it so far. We need to find allies within all sectors of the oral health community and allies beyond the oral health community because important elements of the relevant systems are out there. We need to share what we learn not only with one another, but with our allies as well.
And this takes us to another, less obvious lesson from Werhane’s article. If we think that we—meaning persons who might take up this cause within the oral health community—are going to be able to address this important issue by our own leadership as dental professionals alone, we are foolish. We absolutely need allies, who will eventually become collaborators and then co-leaders in the project, and we need them in each of the sectors of Werhane’s diagrams. That means we have to be willing to share leadership with them as well. And, perhaps the hardest step of all, we have to be modest enough about our self-importance to be perhaps only the catalysts and to see others who are in fact more powerful (or even more effective) than ourselves be the ones finally credited with fixing the system in the ways we hope for. It is possible that the world will credit someone else with the achievement if and when it is accomplished, and we have to be able to accept that.
But again the first step is to begin exercising our moral imaginations and doing our systems thinking, and then finding allies and helping them to do this as well. Unless I am mistaken, many of the institutions, groups, and individuals represented on Werhane’s diagrams also see the problem of inadequate access and also consider it a serious problem that needs addressing. Their motivations for assigning ethical priority to access may not be exactly the same as those of the oral health professions and their members, but many of these other groups also see this issue as ethically significant. That is good news, because most of them probably do not need to be persuaded to care about this issue. What is holding them back is most likely their inability, like ours, to imagine how they can hope to possibly do anything useful acting as a lone voice and a solo actor in a terribly complex situation. Many of them, I am suggesting, are also stuck in saying: "We will never get all of these players to agree on anything, much less to actively coordinate what they do to be responsive to what the other players do."
So I suggest that what Werhane has offered us is not just an excellent analysis of the problem. It is also a most practical insight into what we need to say first to all our potential allies in this effort. Our first message to ourselves and to every one of our potential allies needs to be: "This is a systems problem, and of course none of us can address it meaningfully alone. But that is not a reason for inaction. Instead, it is a sign of how we need to proceed. You are on Werhane’s grid and so are we. Let’s work together; let’s get everyone on the grid working together."
Finally, to say the same thing in a different way, let me offer a teaching point. I call it "The Myth of Enough Good People."
Many people look at groups, institutions, and systems that are in need of correction or improvement and see them populated with people, some of whom are already sensitive to the issue and others of whom are less so, something that is obviously true. They therefore conclude that, since the correction or improvement is not happening, what is needed must be to get more of these individuals committed to it, and that will solve the problem. Of course, a critical mass of individuals, especially those in positions of power and leadership, will need to be involved for the correction or improvement to happen. But just getting enough good people is not enough.
Groups, institutions, and systems do what they do partly because of the people who make them up, but only partly. They also do what they do because of how they are structured, because of their systemic values and goals—that is, as systems. Their structures and values and goals, how they work as systems, set the parameters for individual action and determine the tasks that individuals can undertake. They also structure the evaluation systems within which the good people work. Even if there are more than enough good people, if the systems within which they work are not of the right sort, the desired change in outcome will not happen. Of course, no system will ever change without the work of enough good people. But simply having enough good people involved will not by itself change the structures, values, and goals of a complex system, will not change it as a system.
So another way of stating the lesson of Werhane’s article is in the form of this teaching point. Werhane has demonstrated that, both analytically, in order to properly understand the challenge of improving access to oral health care, and practically, as the step we and our necessary allies need to take first of all, we need to get rid of "The Myth of Enough Good People." And only systems thinking, starting with Werhane’s moral imagination, will do that.
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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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