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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Key words: professional ethics, access to oral health care
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Limitations to Professional Ethics |
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TopAbstractLimitations to professional...Other approaches to promoting...Summary |
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In some ways this should not be surprising. On one hand, I do believe that most people in contemporary American society understand or presume that physicians and dentists are professionals. There is no other stranger I can think of but a physician for whom I would take off my clothes; but I do so assuming that the physician has an exclusive expertise that I need, that he can provide a fundamental good that I am lacking, and that he will focus more on my needs than on his own personal benefit. Similarly, there is no one other than a dentist that I would allow to probe and treat in my mouth, and for the very same reasons. But on the other hand, I believe it is also safe to say that most of us do not personally experience—and thus do not presume—that health care professionals, whether they are physicians or dentists, have a special obligation to provide or to promote access to the fundamental social goods of medicine or dentistry for which those professionals alone (according to traditional understandings of professionalism) have been granted exclusive expertise to provide. I believe that most people in our society view the professional ethics of physicians or dentists in a much more limited way, namely, within the context of the one-on-one relationship with their professional caregiver. But if I have a toothache and am without insurance and the means to pay for needed dental services, I, and I believe most Americans, would not expect a dentist to feel obligated to take care of me. I would be grateful if the dentist felt this way, but I would understand the provision of free services to be a matter of charity and not something that I have a right to, of "going above and beyond the call of duty," and as a reflection of his or her own personal values rather than any kind of professional obligation required of all dentists everywhere.
While we like to refer to dentists and physicians as professionals, I believe most people encounter them within the framework of a commercial model. Most people experience dentists within the context of required payment (or proof of payment) up front, with optional or cosmetic services (such as teeth whitening) marketed to them along with supposed (since within a retail model the consumer always has an element of doubt) necessary services, and with general ignorance about any charitable services individual dentists may provide to those without means to pay. Because most people understand that, outside of being able to access health care through an emergency room or charity clinic, their health problems (particularly oral health problems) are their own, there is not a common presumption (among the general population or even among dentists) that dentists have a special obligation as members of a profession to provide or to promote access to oral health. If this is the case, then it seems clear that professional ethics alone is inadequate for formulating a convincing moral argument for dentists to provide or to promote access for oral health. Professional ethics, therefore, either in its understanding or in its implementation by dentists as a professional group, is hampered or limited by the reality of applying it within a commercial model of transactions of dental services in exchange for money. As a result, the difference between dentists who provide a considerable amount of charity care to those unable to pay for needed oral health and those dentists who provide little or no charity care tends to be understood in terms of a difference in personal values—or of different personal understandings of one’s professional responsibilities—rather than the fulfillment or lack of fulfillment of commonly agreed upon professional responsibilities.
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Other Approaches to Promoting Access to Oral Health Care |
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Personal Values
With regard to appealing to personal values, I once encountered a particular physician who successfully lobbied a few of his physician friends to staff a free medical clinic a few hours a week. As the need for referral to medical specialists arose, that small group of doctors successfully lobbied specialists to occasionally see indigent patients in their office for free. As the need for particular medical services arose, those specialists successfully lobbied hospitals to provide those services to specific patients for free. While this overall effort eventually involved a considerable amount of community resource networking and required coordination through paid positions financed by grants, the impetus as well as the sustaining force for providing and promoting access to needed care came from a few individual physicians. They were personally motivated to help the uninsured who lacked adequate means to pay for needed health care resources. The other physicians who agreed to help most likely did so for a variety of reasons: friendship with the initiating physicians, a desire to avoid feeling guilty as their colleagues each pitched in, and/or a personal sense of altruistic satisfaction for charitably doing something good for free, along with many other reasons.
These same actions, and motivations, could and probably do occur among dentists. If individual dentists begin publicly to provide a limited amount of free dental care to those without ability to pay and were willing to encourage their peers to do the same, a sizeable number of dentists within a given community could make a significant impact on access to needed oral health care in their community. There need not be an appeal to professional ethics to motivate everyone. Instead, there are other values that can be appealed to in order to motivate various dentists to offer a limited amount of free oral health care. The challenge is finding the one or more initial dentists with the personal motivation (and the connections to and the respect of their dental colleagues) both to provide access to oral health and to promote the provision of access to oral health care among their colleagues.
At another small community hospital (the only hospital in town), I encountered some physicians who were willing to see indigent patients while others did not. Those who were willing to treat patients regardless of their ability to pay found that indigent patients were making up a significant portion of their patient clientele. Because this was a small community, their complaints about this inequity embarrassed the other physicians. Conversations held about this in medical staff meetings resulted in all the physicians agreeing to see charity care patients up to a certain percentage of their clientele. They even agreed that their office managers would share the numbers and cost of treating indigent patients with one another to ensure that all physicians were seeing their fair share.
Again, the motivation for a number of these physicians did not seem to derive from any strong professional ethic, or even from their own personal values regarding the poor and their access to needed health care. They seemed to be motivated for far less noble reasons, but regardless, access was improved in that community. While this situation is distinct in that the small community size facilitated the physician interaction and their felt obligation to one another and to their own public image, a similar experience could occur among dentists with regard to providing access to oral health care. Again, the key is for particular champions, who may be motivated by a professional ethic or perhaps only by a self-serving interest to more equitably distribute the burden of caring for the poor, to find what appeals to the personal values of other dentists—whatever those values may be—in order to motivate them to provide access to oral health care for those with limited means to pay. In this framework it does not matter what is the motivation, and so there may be little need to appeal to a professional ethic for all. What is needed is one or more initiators of change, who value access to oral health care for whatever reason(s), and who have the insight and leverage to know how to appeal to all kinds of personal values to motivate other dentists to provide access to oral health care to those in need.
Organizational Strategies
My experiences with health care organizational ethics and strategies suggest a couple of other approaches for the ethics education of dental students with regard to access to oral health care. First, many health care organizations today strongly emphasize leadership development. In addition, successful organizations know and articulate their core values, and these core values ground and shape their key strategies and decisions. Increasingly, leadership skills development is being complemented with training in values integration out of recognition that personal integrity and personal identification with the organization’s values are critical factors in the success of leaders. While there are obvious differences between organizations and professional groups, dentists as a professional group could elect to acknowledge that access to oral health is (or should be) a fundamental value for them as a group, regardless of how the obligation to provide for this is understood or interpreted. Then, as a professional group dentists could decide that this value can be one of the values to ground and shape the education experience of dental students.
Many health care organizations have come to understand that organizational values are not taught in one course, but must be intentionally visible or consistently implicit in all educational efforts. In my own experience, if maintaining good and caring relationships is understood to be a hallmark of Catholic health care, then leadership development efforts must consistently incorporate that characteristic within all of its curriculum. Similarly, if access to needed oral health care is understood or agreed upon as a principle value for the dental profession, then dental schools could commit to include a focus on or discussions about the professional obligation of dentists toward access to oral health in many or in most of their curricula. It would not be addressed merely in the context of a single ethics course, but a focus on access to oral health would be integrated throughout the education process with stories, testimonials, reflections and personal sharings, heart-rending images, and personal experiences with the poor, along with philosophical arguments. This could be continued after dental school in the ongoing education of dentists with regular perspectives on and arguments for access to oral health care in conferences and journals. Again, it does not seem necessary to state what providing or promoting access to oral health actually requires of individual dentists; what is important is that there is an intentional focus on integrating this value throughout the dental education process to cultivate and nurture this value in young dentists.
In addition to leadership development efforts, successful health care organizations increasingly are learning to select their leaders not only for "job fit" but also for "organizational fit." In other words, leaders may have clinical or business proficiency, but may not be a good "fit" for their organization in terms of values and culture. Leaders may have the right job skills, but it is essential that they can function and thrive within the particular culture of their organization. Increasingly, health care organizations screen and select candidates as much for their cultural fit with the organization as for their specific job skills.
Dental education can provide skills development. It is unclear, however, how much personal character formation can occur in dental education. Some suggest that one’s personal values are formed early in life or certainly are well in place long before students come to dental school. Once again, just as health care organizations identify and then select their values, if dentists as a professional group would agree that access to oral health is a fundamental value for them as a group and should be part of the cultural make-up of their group, then applicants for dental school could be assessed in light of their commitment to this. Candidates would be screened for evidence of charitable outreach and for aptitude for, openness to, and appreciation of the value of access to oral health care. Intentionally selecting candidates who personally value or who have a sense of professional obligation to provide or promote access to oral health care will help foster a culture promoting this value among dentists as a professional group.
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