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The Ethical and Practical Aspects of Acceptance and Universal Patient Acceptance

Key words: Acceptance, Universal Patient Acceptance, health care reform, health care access and accessibility, patient selection, risk management, social responsibility, ethics, dental ethics, bioethics

	Abstract

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"Acceptance" is an often presupposed, hidden core value and ethic focused on how dental and other health practitioners first accept people as possible patients. The three basic styles of patient acceptance are random, selective, and universal. Reduced public access to care results from the practice of random and selective acceptance. Only universal acceptance creates a potential pathway for improved access to care. The notion of Universal Patient Acceptance (UPA) is discussed here as one kind of applied ethical tool or clinical practice that allows for the ethic of acceptance to be more effectively pursued in daily practice. We suggest that health providers falsely surmise that they already understand and practice Universal Patient Acceptance. That myth and perspective are partly what keeps Acceptance hidden as an ethic and overlooked as a potential way to foster dialogue and indirectly promote better access to care. Without Universal Patient Acceptance, dental and health providers will continue to silently engage in practice patterns that adversely affect public access to care. The actual benefits of Universal Patient Acceptance are the subject of ongoing review and debate. Whatever those benefits might be will not likely be realized until Acceptance and Universal Patient Acceptance are included as part of dental and other health professional codes of ethics and training curricula. That is what we argue for here.

Acceptance is the first of four steps (acceptance, diagnosis, treatment, and payment) involved in the process of a person becoming a patient. That journey from person to patient begins when a person asks for help. A dialogue must then take place between the provider and that person to determine the need for care and possible avenues through which that care can be accessed as a patient. We use the proper noun of Acceptance to describe this act and the ethical principle that underlies this initial encounter between providers and prospective patients.

Acceptance begins when health professionals honor an ethical responsibility to talk with persons who have asked for help and engage them in dialogue related to their health. This first step of Acceptance is mostly unnoticed and hidden because it is so inconspicuously part of the more visible health care actions of diagnosis and treatment.

Accepting, talking to, and guiding patients might seem to be a simple practice, one that ethicists and health providers likely presuppose and believe they already adhere to and accomplish. However, Acceptance may not be so transparent or manifest, as demonstrated by health providers who seem to engage in various styles of Acceptance that result in the creation of barriers to access. The three basic types and styles of Acceptance are random, selective, and universal.

Random acceptance is practiced when providers do not specifically plan their actions to determine which persons will be seen for discussion and perhaps treated. Office location, hours of operation, and languages spoken are types of actions that contribute to patterns of random patient acceptance, which nonetheless result in the unintentional exclusion of patients. For example, an office that is wheelchair-inaccessible leads to exclusion and reduced access to care.

Selective acceptance is an intentional process that specifically seeks to limit who can be seen and treated. Managed care companies select patients based on employer or insurance groupings. Providers who refuse health welfare recipients exclude patients based on finances and ability to pay. Non-generalist, highly specialized health providers limit their exposure to the public by speaking only with those people who appear before them subsequent to a referral process. All such acts result in the intentional, selective acceptance of some patients and the exclusion of others.

Universal acceptance intends to remove barriers that accidentally or intentionally keep people from being accepted for a dialogue with a health care professional. Universal Patient Acceptance (UPA) is a practice based on an ethical commitment to speak with every prospective patient who contacts a provider to learn if he or she should become a patient, the type of care needed, and options for how that care can be acquired. UPA does not imply an obligation to diagnose, treat, or be held accountable for abandonment, nor does it necessarily require that doctoral providers be the ones who individually meet with patients. But in tandem with that is the argument that if doctors don’t really understand the nuances of Acceptance and Universal Patient Acceptance, there seems little chance they can correctly communicate the idea or expect others to responsibly carry it out for them. What needs further discussion here is the ethical basis of UPA, the potential relationship between UPA and improved access to care, and the reasons why Acceptance and UPA seem to qualify as reasonable additions to dental and other health professional codes of ethics and training curricula.

	Discussion

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The policies of individual providers and institutions can intentionally or unintentionally limit access to care. Such practices restrict access to care for those patients seen as undesirable, or with no ability to pay, and even for some that are insured. For example, there are educational programs that readily encourage and teach providers how to pre-select and/or dispose of patients.² Newly developed computer software allows health professionals to categorize patients with regard to clinical needs, personality, and ability to pay, thus making the selection and rejection of patients more efficient. These technologies seem specifically designed to exclude vulnerable populations from health care access.³ Cash-only and fee-for-service practices also have the potential to exclude certain patients. Even agencies may impose such practices upon the individual providers they employ, suggesting that the ethical behavior of institutions can adversely impact access to care.

Such denials of care occur at the expense of other providers who must then manage and treat a disproportionate number of patients rejected by other practices.⁴ Actions like these can weaken the commitment to communities that health professionals are entrusted to serve. The ethic of Acceptance underlies and reflects those commitments and is related to issues of fidelity and stewardship. We believe that problems arise for patients, providers, and society whenever health professionals fail to practice and convey Acceptance to all persons. Our proposal is that access to care is better promoted when health professionals understand their ethical responsibility and obligation to routinely practice Universal Patient Acceptance.

Acceptance does not imply that providers must completely cease to specialize or manage their availability. Also, the act of Acceptance does not mean a requirement to provide diagnostic, treatment, and financing services to all persons/potential patients. Acceptance is mainly the ethical responsibility of providers to discuss with potential patients their situation and, if necessary, help to ensure some mechanism by which they can access care. Making this dialogue available seems to be an ethical imperative, justified by the history, traditions, and ethics of many health professions.^5,6

Obviously, just talking with potential patients will not always lead to the acquisition and delivery of care if it is needed. But there is some precedent for the idea that talking is an important precursor for problem solving, for the building of an effective community and perhaps more actively addressing access to care problems within that community.⁷ In this light, Universal Patient Acceptance could probably be described as an indirect and mildly confrontational approach to improving dental and general health care access. That is, if the health care professions and providers within those professions are confronted with and compelled to have some discussion with all potential patients, then the gross inadequacies and inequities in our health care delivery system might be less easily ignored or denied.

Such an increased awareness might prompt further discussion and action amongst providers and all of society, so that access to care problems might be more appropriately addressed. That is why we believe that this supposedly simplistic notion and requirement to just talk with patients might be a worthy enterprise. At this point, we offer no scientific proof that such a process would work. Nonetheless, there is considerable scholarly support for the idea that discussion is often the initial foundation upon which productive change is built.⁸ To reasonably promote Universal Patient Acceptance in this context, we need to demonstrate that Acceptance is a core value and an important health care ethic.

Acceptance is a normative ethical principle centrally related to the applied ethical issue of access to care. The notion of Universal Patient Acceptance is constructed to be one kind of applied ethical tool or strategy that allows for the ethic of Acceptance to be more effectively pursued in daily practice. The aspiration is for UPA to be the starting point for a dialogue among patients, providers, and society that fosters discourse, strengthens communities, and results in community solutions that improve access to health care. Some type of paradigm shift seems required, however, if UPA is to become a routine part of dental and health care practice. To accomplish that, the ethic of Acceptance and the practice of Universal Patient Acceptance need to be made explicit in codes of ethics and in the curricula for dental and health care professional training. That is what we argue for here.

Just because Acceptance is a core value and ethic does not mean it is yet understood to be a required professional, ethical standard or published in the ethics codes of health professionals. A review of existing ethics codes suggests that the ethic of Acceptance is hidden and not adequately expressed as part of the more prominent, commonly visible ethics and principles. The American Dental Association code of ethics is constructed around only five ethical principles that approximate those identified in the basic textbook on medical ethics by Beauchamp and Childress.⁹ The fact that only five ethical principles are identified in this textbook has not prevented ethics scholars and other health professions from considering a somewhat broader array of moral values and ethics that underlie and guide health care delivery. Autonomy, nonmalfeasance, beneficence, justice, and veracity are all critical and central issues, but they may not be the only issues.

Since the ethic of Acceptance and the practice of Universal Patient Acceptance are somewhat newer concepts, an explicit reference to them does not yet appear in codes of ethics. The American Dental Association and other professional codes of ethics do speak clearly to the related issues of fairness, justice, and dignity and include such phrases as "shall deal with people justly and deliver care without prejudice." And most codes nicely convey the idea that providers "support activities that will improve access to care for all." The ethics codes for physicians, psychologists, and a variety of other health providers also speak to such things as dignity, confidentiality, fidelity, and sanctity of life, to name but a few. As a core value and ethic, Acceptance seems a reasonable candidate to be added to this list.

Admittedly, health providers already know about and embrace the idea that they are to help promote access to care and generally not show prejudice in terms of who they treat. But the point here is that providers may know far less about the possible types of unfairness they might engage in before treatment begins, including the unfairness resulting from the subtle barriers created by random and selective acceptance. These barriers can prevent people from ever being accepted for discussion about their possible treatment needs. If the concepts of Acceptance and UPA are not present in codes of ethics and made part of the discussion in dental and health education classrooms, then random and selective acceptance will likely persist.

	Conclusion

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This article describes how easy it might be for ethicists, dentists, and health providers to presuppose and falsely surmise that they already fully understand, promote and/or practice Universal Patient Acceptance. That myth and perspective are partly what keep Acceptance hidden as a neglected, unscrutinized ethic that is missed as a potential way to promote better access to care. However, the inclusion of Acceptance and Universal Patient Acceptance in dental/health ethics codes and professional health education curricula will not by itself completely reshape access to care.

Full access to care requires multidisciplinary support from many parts of society and a reform of existing public policy, law, and financing. Yet, a recent report states that economic and political solutions, as well as social solutions like patient education, are insufficient to effectively remove barriers to health care access.¹⁰ Instead, fuller access to care appears somewhat dependent on changes in professional provider education and behavior, as well as a continued national dialogue about how to achieve health care for all.¹¹ Universal Patient Acceptance speaks to changes in individual provider behavior and establishes the starting point for a dialogue between patients, providers, and society intended to foster discourse, strengthen communities, and result in community solutions that improve access to health care. There is nothing in the practice of UPA that implies dentists and other health providers must sacrifice all personal interest to accomplish this.

The point is that any benefits that might arise from the practice of UPA won’t likely be experienced until Acceptance and Universal Patient Acceptance are included as ethical concepts and standards in health professional codes of ethics and presented in health education training curricula. Those actions seem necessary if the myths and misunderstandings about Acceptance and Universal Patient Acceptance are to ever be dispelled.¹²

Full access to care is clearly a multidimensional phenomenon and a dilemma far more challenging than what theoretical ethicists and health professionals can resolve on their own. But, if dentists and other health professionals elect not to endorse UPA, make it explicit in their codes of ethics, and educate providers about its practice, that gives tacit approval to the ongoing practice of random and selective acceptance. The idea is that injustice and reduced access to care will persist as long as random and selective acceptance continues.

Empirical evidence is not presented here that would quantify the extent of that injustice and diminished access or the level to which those might be reduced with the implementation of Universal Patient Acceptance. The final common pathway for full access to care depends on something more comprehensive than what UPA, and the dialogue it promotes, can alone provide. Nevertheless, we cite but a few of the many available scholarly references to support the notion that discussion is often the initial foundation upon which productive change is built. Universal Patient Acceptance is only a single small step toward that goal, but one that seems worth taking.

	Footnotes

 
Dr. Corsino is President of Bioethics, Inc., in Reston, Virginia, and Adjunct Associate Professor of Psychology at Virginia Tech; Dr. Patthoff is in the private practice of general dentistry in Martinsburg, WV. Direct correspondence and requests for reprints to Dr. Donald E. Patthoff, 300 Foxcroft Avenue, Martinsburg, WV 25401; 304-263-0411 phone; 304-263-3288 fax; dpatthoff{at}peoplepc.com.

	REFERENCES

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2. Yalden CA. Medical billing: the bottom line—an entrepreneur’s guide. Rev. ed. Kearney, NE: Morris Publishing, 1999.
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4. Mithers CL. The ER crisis. Ladies Home Journal, July 2001:70–9.
5. American Dental Association. Principles of ethics and code of professional conduct. Chicago: American Dental Association, 1999.
6. American Medical Association. Principles of medical ethics. Chicago: American Medical Association, 2001.
7. Cahill LS. Theological bioethics: participation, justice, and change. Washington, DC: Georgetown University Press, 2005.
8. MacIntyre A. Edith Stein: a philosophical prologue, 1913–1922. New York: Rowman & Littlefield, 2005.
9. Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. New York: Oxford University Press, 2001.
10. Lewin ME, Altman S, eds. America’s health care safety net: intact but endangered. Washington, DC: National Academy Press, 2000.
11. LeBow RH. Health care meltdown: confronting the myths and fixing our failing system. Chambersburg, PA: A.C. Hood, 2003.
12. Jones K. Mea culpa—not. ODA Today (Ohio Dental Association), August 2005.

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				B. A. Largent Reaction to Universal Patient Acceptance: The Perspective of a Private Practice Dentist. J Dent Educ., November 1, 2006; 70(11): 1202 - 1207. [Abstract] [Full Text] [PDF]

				B. Peltier Codes and Colleagues: Is There Support for Universal Patient Acceptance? J Dent Educ., November 1, 2006; 70(11): 1221 - 1225. [Abstract] [Full Text] [PDF]

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