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Reaction to Universal Patient Acceptance: The Perspective of a Private Practice Dentist

Key words: ethics, access to care, patient selection

	Abstract

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The purpose of this article is to respond to the theories of Acceptance and Universal Patient Acceptance and their relationship to the American Dental Association’s Principles of Ethics and Code of Professional Conduct (ADA Code). Universal Patient Acceptance (UPA) requires the dentist to communicate in some fashion with each patient who attempts to enter his or her practice to determine needs, desires, and financial ability to access dental care. The dentist must then help the patient gain entry into his or her practice or make appropriate referrals based on the patient’s desires, needs, and financial status. The theory of UPA proposes that this action will alleviate some portion of the access problem. This article explores the notion of access as articulated in the ADA Code. The theory of UPA is explored from the view of the practicing dentist, noting the difficulties encountered when incorporating this theory into private practice. The conclusion is that the ADA Code offers appropriate guidance for ADA members regarding the ethical treatment of the underserved. Without further study, the inclusion of UPA in the ADA Code is not desirable. The author also concludes that support systems for the practicing dentist are necessary before UPA could be considered a reasonable way to practice dentistry.

Before decisions can be made as to whether UPA should be explicitly articulated as responsibilities in professional codes of ethics, further study and analysis are needed. Such future study to justify their inclusion should encompass the positive outcomes of applying the principles and balancing them with other principles that improve access to care. The theories of Acceptance and UPA would appear to be reasonable parts of the puzzle of access to care. If every individual could feel that there is an answer to his or her dental problem and a dentist to help that individual receive an answer and ultimately treatment, ours would be a better society. The idea of Give Kids A Smile Day began as a way to showcase the needs of the underserved and has evolved into a major health care day and, in some instances, much more. Anything is possible. Let’s take a closer look at Universal Patient Acceptance.

	How Are Acceptance and Related Topics Reflected in the Codes of Ethics?

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Corsino and Patthoff propose two concepts in their article, with a goal to help improve access to care. Acceptance is described as an ethical responsibility to discuss with potential patients their situation and, if necessary, help to ensure some mechanism by which they can access care. Universal Patient Acceptance (UPA) is a style of practice based on a commitment to speak with every prospective patient who contacts a provider to learn if he or she should become a patient, assess the types of care needed, consider the options for how that care can be acquired, and take responsibility to get that person into the professional health care network. "Acceptance" is defined as the "normative ethical principle centrally related to the applied ethical issue of access to care." In contrast, UPA is said to be the applied ethical tool or strategy that allows for the ethic of Acceptance to be more effectively pursued in daily practice. Social justice, nonjudgmental regard, and the commitment to improve access to care are referenced as related topics.

As Corsino and Patthoff have stated, the specific concepts of Acceptance and UPA appear to be newly articulated and as such are not explicitly stated in the code of ethics. The ADA Principles of Ethics and Code of Professional Conduct (ADA Code), however, does reflect some of the essence of the ethic and related subjects.

The principle of beneficence, as stated in the ADA Code, provides that "the dentist’s primary obligation is service to the patient and the public-at-large. The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient." The ADA Code’s principle of justice expresses the concept that "the dentist’s primary obligations include dealing with people justly and delivering dental care without prejudice." In its broadest sense, the principle of justice expresses the concept that the dentist is obliged to work within society to help improve access to care for all persons. Section 4A of the ADA Code provides that dentists are obliged to make reasonable arrangements for emergency care of their patients of record, as well as for those patients not of record. This is indeed a form of the acceptance of all, albeit a "selective" acceptance.²

It may be helpful to refer to the code of ethics of our physician colleagues. In the preamble to the American Medical Association’s Principles of Medical Ethics in the Code of Medical Ethics (AMA Code), the following appear relevant. In Principle VI, the physician is provided the choice of whom to serve, with whom to associate, and the environment in which to provide medical care. In Principle IX, similar to the ADA Code, the physician is required to support medical care for all people.³ The codes are similar, both stating that the practitioner cannot refuse to care for patients based on race, gender, or sexual orientation. The AMA Code specifically states that physicians have an obligation to share in providing charity care for the poor, but not to the degree that would seriously compromise the care provided to existing patients. The AMA Code also outlines "Potential Patients, Ethical Considerations" and "The Provisions of Adequate Health Care."^4,5

There are similarities and differences between the ADA Code and the AMA Code as to patient acceptance and selection. Both codes address Corsino and Patthoff’s proposed ethic of Acceptance to varying degrees, but neither explicitly advocates any of the ideals of UPA. Comparing the ADA Code and the AMA Code illustrates differences in depth of the directives, but does not expose deficiencies in either code. Both codes are voluntary. It is important to note that while the AMA Code is more specific, it binds less than 30 percent of the practicing physicians in the United States due to its membership.

The ADA Code embodies the obligations of the dental profession to society, with respect to the special position of trust given to the professional as a dentist within society. The ADA Code is a "written expression of the obligations arising from the implied contract between the dental profession and society."² Adherence to the ADA Code is a voluntary agreement entered into when a dentist becomes a member of the ADA. There are three main components of the ADA Code: the Principles of Ethics, the Code of Professional Conduct, and the Advisory Opinions. As noted above, the Principles of Ethics are the aspirational goals of the ADA Code. The Code of Professional Conduct is an expression of the conduct required of or prohibited for the dental professional. The Advisory Opinions are interpretations of the Code of Professional Conduct for specific situations. The ADA Code is an evolving document and is not intended to articulate specific behavior for every situation. Besides justice and beneficence, the ADA Code includes the principles of patient autonomy, nonmaleficence, and veracity.

The ADA Code, then, is both aspirational and explicit. As stated in the introduction, the Principles provide guidance and offer justification for the Code of Professional Conduct and the Advisory Opinions. The five fundamental principles were added in 1996 when the ADA Code was reorganized to better serve as a guide to dentists looking for practical answers to the dilemmas they confront on a daily basis. In developing the organizational framework, the ADA Council on Ethics, Bylaws, and Judicial Affairs sought input from several ethicists. The order of the principles does not convey a rank or priority. As the introduction makes clear, "the principles can overlap or compete with each other for priority" and "may at times need to be balanced against each other." The principles are the profession’s firm guideposts.

The Principles and the Code of Professional Conduct are a result of resolutions passed by the ADA’s governing body and are binding on ADA members. It is important to note that ADA membership includes over 70 percent of practicing dentists in the United States. Violations of the Code of Professional Conduct may result in disciplinary actions through the ADA’s tripartite system.

While patient acceptance, in its broadest definition, is covered in the goals, the concepts of Acceptance and UPA are not explicitly stated. However, the profession is hardly silent on the subject of access to care. Consider the American Dental Association’s Vision Statement on Access for the Underserved⁶:

Resolved, that the American Dental Association and its members will continue working with policymakers to establish programs and services that improve access to oral health care, while maintaining a single standard of oral care; and that the Association urges the nation to join it in:

• rejecting programs and policies that marginalize oral health, and instead supporting those that recognize that oral health is integral to overall health and can affect a person’s self-esteem, ability to learn, and employability;
  
• acknowledging that the degree of oral health disparities and the extent and severity of untreated dental disease— especially among underserved children— is unacceptable; and
  
• committing, through both advocacy and direct action, to identify and implement common sense, market-based solutions that capitalize on the inherent strengths of the American dental care system and that make it possible for all Americans regardless of their financial, geographical, physical, or other special circumstances to experience optimal oral health.
  

This vision statement is reflected in the 2004 American Dental Association white paper on improving access to dental care for the underserved. This white paper offers five models for access, which can be adopted and modified to meet specific needs in a given area. Three models take a comprehensive approach to increasing dentist participation in public programs and improving utilization of dental services. Two community models increased access to care by expanding dental delivery sites. The white paper, the ADA’s Dental Medicaid Reform Core Principles and Policies,⁷ and numerous other policies and actions articulate the position of the profession and dentists on access to care, particularly for dental Medicaid beneficiaries.

The ADA has long supported the efforts of dentists and dental societies to improve access to care, and the majority of dentists quietly provide some form of charitable care.⁸ For example, an ADA survey of dentists (2,888 usable responses) showed those surveyed annually donate about $8,323 of free care and $28,175 in discounted care. Seventy percent of the survey respondents reported they provide charitable care in their private practices.⁹ Through a Mission of Mercy in New Orleans in February 2006, 425 volunteers from thirty-eight states (239 dentists) provided almost $2 million worth of dental care to 4,000 individuals, most of whom were victims of Hurricane Katrina.¹⁰ Several state dental societies operate Mission of Mercy projects.

In addition to individual, local, and state charitable efforts, there are many large national efforts such as the ADA’s Give Kids A Smile Day (GKAS), a national initiative that focuses attention on the epidemic of untreated oral disease among disadvantaged children. Held each February, GKAS provides free oral health education, screening, and treatment services to children from low-income families. During the fourth annual celebration of GKAS in 2006, 12,000 dentists and 27,000 dental team members provided free dental care valued at $41 million to some 500,000 disadvantaged children across the nation.¹¹ Data available for the three previous GKAS initiatives indicates similar information. According to the National Foundation of Dentistry for the Handicapped, since its inception in 1986 almost 50,000 disabled, elderly people and medically compromised adults in thirty-four states have received over $60 million worth of free, comprehensive donated treatment.¹²

So what is the consequence of "silence" on Acceptance and UPA in the ADA Code? Silence opens the door to many more solutions on access to care. This allows the individual to determine the best way to work within society to open the doors of access. Perhaps it is monetary donations, or participation in the Medicaid system, or charitable treatment, or volunteering for a community service organization or political/social advocacy. Let us not limit the practice of ethical dentistry to those who have poverty of resources or a poverty of knowledge.

Ethical treatment of all patients is the goal of the ADA Code. UPA primarily addresses those persons who do not traditionally access care in a private office, placing the burden of solving the access problem entirely on the practicing generalists, requiring them to spend their time navigating the current systems for referrals and conducting exams that may not effect any treatment.

Inasmuch as Acceptance and UPA appear to be newly articulated concepts, further study is needed to better understand them. It would be helpful to know about the positive outcomes of applying UPA in dental practice and how it compares with other principles and activities. Why, for example, should UPA be articulated instead of another obligation, such as a specified number of community service hours that could be met through activities such as school-based prevention and sealant programs, Give Kids A Smile Day, or nursing home care? If dentists are willing to agree to UPA as an ethical responsibility, will the rest of society provide the necessary support mechanism in concert with dentists to make UPA work? While the actual resources needed have yet to be identified and explored, some that come to mind include transportation, cultural assistance, language assistance, recall systems, oral health literacy, overall health literacy, and follow-up self-care. It is known that transportation, cultural views of dentistry, language barriers, and oral health literacy are huge barriers to those currently in the Medicaid system. States that have implemented strategies to overcome these difficulties have increased the use of dental services and the number of providers. These adjunct services are currently limited, and it would be reasonable to assume that, for UPA to be successful, someone other than the practicing dentist would be required to provide these services.

UPA is not patient acceptance in any traditional or legal sense. Webster’s dictionary defines acceptance as "approval" or "the agreeing either expressly or by conduct to act or offer to another so that a contract is concluded and the parties become legally bound."¹³ State laws vary, but when a dentist speaks with a person to discuss his or her oral health situation and to help that person obtain treatment, either in the dentist’s own office or another setting, the practitioner would likely be considered the dentist responsible for that individual until he or she actively chooses another dentist. Legal responsibilities and liabilities with UPA are a consideration that will benefit from further analysis.

It seems impossible to have a meaningful discussion with a patient without first completing at least a cursory dental examination. For UPA to be practiced, all potential patients would have to be examined by the dentist without regard to compensation or insurance coverage. Managing and referring patients with regard to patient preference, ability to pay, and type of insurance appear to be daunting tasks. In practical terms, it would seem that the dentist would be required to perform an in-depth analysis of each patient’s resources to make an appropriate referral within the bounds of UPA. The time devoted to speaking with every potential patient will divert the dentist from the delivery of patient care. For those practices providing services to the Medicaid population, UPA is onerous. The dentist will have no choice as to whom he or she must speak with and assist in obtaining treatment. The mandates of UPA may thwart selection and the delivery of patient care rather than advance them.¹⁴

Time spent discussing a potential patient’s situation is a consultation, which is a professional service. If an equitable fee for the service were to be requested, it would present yet another barrier to access. Training of an employee to provide this service is nearly impossible and not permitted in most jurisdictions.

In our society there are no reasonable and consistent referral sources for individuals without financial means. In most communities there exist limited resources, but they are not so abundant that a dentist can make an immediate referral. These limitations would appear to place the dentist in a most difficult situation, one for which there is no ethical, legal, or moral answer.

UPA imposes a very high ethical standard for those who accept the theory. Medicaid does not cover many services for children and most (all in many states) services for adults. Dentists in private practice have limited resources too. A dentist who can not or does not accept Medicaid or certain insurance programs and who determines a need for the potential patient is then left with referral as the only answer. What if there are no community health centers or no other professionals in the area who participate in Medicaid or accept the patient? Has the patient truly accessed the system, or has he or she spent resources on transportation to learn that there is no one to provide care? Without support systems, UPA becomes yet another lie foisted on the poor in the name of access.

	What Are the Key Features of the Ethics of Access?

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To answer this question, it may be helpful to begin by defining the term "access to care." A traditional definition is related to the patient’s ability to obtain or make use of dental care.¹⁵ In a practice, internal patient factors such as patient needs, cultural preferences, language, and willingness of the patient to seek that care are also relevant. Thus, in speaking of access from the provider’s perspective, considerations should include the availability of dental care, the affordability of care, and the willingness of the patient to seek that care. Dental care can be further defined as that which is "essential" for appropriate and pain-free oral functioning.¹⁶

Based on this definition, the key features of the ethics of access that can be readily identified are justice, beneficence, and patient autonomy. A definitive and theoretical exploration of these principles in relation to access is called for, but it is beyond the scope of this reaction article. For purposes of this discussion, justice can be simply defined as "giving people their due." As to justice, Campbell and Rogers point out that when benefits and harms are present, the ethical consideration is how are the harms and benefits distributed.¹⁷

Of course, the benefits of oral health are a critical element of overall health. The harm that comes from its absence is disturbingly clear, evidenced by the millions of American children and adults who lack the availability of adequate dental care and suffer needlessly from its inevitable results. This is a burden that must be shared by society, the profession, and individual dentists.

An ethical and just society will provide for its least fortunate members. Private philanthropy is a long-standing, traditional source of funding for care of the underserved. Government has an important role in providing resources for access to oral health care for the underserved, through programs, funding, and education. If dentists accept UPA as their ethical responsibility, notions of distributive justice appear to indicate that the rest of society must provide the support needed to make it work. This raises complex social and political questions that warrant further exploration, but again this is beyond the scope of this reaction article.

It is clear that the dental profession and the dentist have ethical obligations to improve access to dental care, grounded in the principles of beneficence and justice. This obligation can be satisfied through many avenues, including removing attitudinal barriers in the private dental office, advocacy, supporting or volunteering in clinics that offer service to low-income families, and providing pro bono care in the dentist’s office. The nation’s dentists have long sought to stem and turn the tide of untreated disease, as individuals through their local, state, and national dental societies and through their community organizations.⁶ Consider the ADA’s sixty-year advocacy for community water fluoridation as one large-scale example of a joint effort of the profession, society, and government.

A similar multifaceted approach is reflected in the AMA’s Medical Code of Ethics, E-9.065 Caring for the Poor: "Each physician has an obligation to share in providing care to the indigent. The measure of what constitutes an appropriate contribution may vary with circumstances such as community characteristics, geographic location, the nature of the physician’s practice and specialty, and other conditions."¹⁸

Another feature of the ethics of access applies to patients or their caregivers if they are dependent on a caregiver. Care given without perceived patient value is fruitless. UPA does not address the important area of patient responsibility. If all barriers to access to care were removed today, we would not improve the dental health of the population without the patient’s interest and cooperation.

The concepts of Acceptance and UPA would appear to be reasonable parts of the puzzle of access to care. If every individual could feel that there is an answer to his or her dental problem, and a person to help them attain an answer and ultimately a treatment, ours would be a better society. We members of the ADA know that anything is possible. Our involvement in Give Kids A Smile Day began as a way to showcase need and has evolved into a major health care day. Before decisions can be made on whether the concepts of Acceptance and UPA should be explicitly articulated ethical responsibilities in codes of ethics, further study appears to be needed on these and other issues:

• If dentists agree to UPA, will the rest of society provide the other support mechanisms needed to make it work? These mechanisms include, but are not limited to, transportation, cultural and language assistance, recall systems, oral health literacy, and follow-up self-care.
  
• What are the bioethical principles at stake with UPA? What are the obligations of all of society to work together on this problem?
  
• What are the positive outcomes of applying UPA? How does it weigh against other principles that promote access? Does its weight warrant articulation in codes of ethics over other principles that promote access, such as community service? Why UPA?
  
• Would society remove legal risks and liabilities now imposed on providers when they accept an individual as a patient?
  

Organized dentistry has led the way in advocacy and charitable treatment. We have not yet reached our goals, but each step brings us closer. Let’s take a closer look at Universal Patient Acceptance.

	Footnotes

 
Dr. Largent is in the private practice of pediatric dentistry in Paducah, Kentucky, and is a member of the American Dental Association’s Council on Ethics, Bylaws, and Judicial Affairs. Direct correspondence and requests for reprints to her at 3008 Oregon Street, Paducah, KY 42001; 270-554-5437 phone; 270-554-5236 fax; drlargent{at}comcast.net.

Disclaimer: The views expressed in this article are those of the author and do not necessarily represent the views of the Council on Ethics, Bylaws, and Judicial Affairs or official policy of the American Dental Association.

	REFERENCES

Top Abstract How are acceptance and... What are the key... References

 

1. Corsino BV, Patthoff DE. The ethical and practical aspects of acceptance and universal patient acceptance. J Dent Educ 2006; 70(11):1198–1201.[Abstract/Free Full Text]
2. ADA principles of ethics and code of professional conduct, with official advisory opinions. Chicago: American Dental Association, January 1, 2005.
3. American Medical Association. AMA principles of medical ethics. At: www.ama-assn.org/ama/pub/category/2512.html. Accessed: July 2005.
4. American Medical Association. Opinion E-10.05. Potential patients. AMA medical code of ethics. At: www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-10.05.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-9.132.HTM&nxt_pol=policyfiles/HnE/E-10.01.HTM&. Accessed: July 2005.
5. American Medical Association. Opinion E-2.095. The provision of adequate health care. AMA medical code of ethics. At: www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-2.095.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-1.02.HTM&nxt_pol=policyfiles/HnE/E-2.01.HTM&. Accessed: July 2006.
6. American Dental Association. State and community models for improving access to dental care for the underserved—a white paper. Chicago: American Dental Association, 2004.
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8. Jasek J, Klyop J, Landman P. Advancing dentists’ charitable dental initiatives—an American Dental Association perspective. J Am Coll Dent 2004; 71(1):6–9.[Medline]
9. American Dental Association Survey Center. 2000 survey of current issues in dentistry. Chicago: American Dental Association, 2002.
10. Crozier S. Mission of mercy brings relief, hope to New Orleans. ADA News. At: www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1819. Accessed: July 2006.
11. Hoyle J. It’s give kids a smile. At: www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid=1776. Accessed: July 21, 2006.
12. National Foundation of Dentistry for the Handicapped. DDS: find local services free, comprehensive dental care for elderly, disabled, and medically compromised adults. At: www.nfdh.org/DDS.html. Accessed: July 2006.
13. Webster’s seventh new collegiate dictionary. Springfield, MA: G. & C. Merriam Company, 1965.
14. Mofidi M, Rozier RG, King RS. Problems with access to dental care for Medicaid-insured children: what do caregivers think? Am J Public Health 2002; 92(1):53–8.[Abstract/Free Full Text]
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16. Ozar DT, Sokol DJ. Dental ethics at chairside: professional principles and practical applications. St. Louis: Mosby, 1994.
17. Campbell CS, Rogers VC. The normative principles of dental ethics. In: Weinstein BD, ed. Dental ethics. Philadelphia: Lea & Febinger, 1993.
18. American Medical Association. Opinion E.9.065. Caring for the poor. AMA medical code of ethics. At: www.ama-assn.org/apps/pf_new/pf_online?f_n=browse&doc=policyfiles/HnE/E-9.065.HTM&&s_t=&st_p=&nth=1&prev_pol=policyfiles/HnE/E-8.21.HTM&nxt_pol=policyfiles/HnE/E-9.01.HTM&. Accessed: July 2005.

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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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