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Critical Issues in Dental Education |
Key words: social responsibility, economics, professionalism, oral health disparities, access to care, ethics, qualitative research
Submitted for publication 04/24/07; accepted 10/08/07
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Abstract |
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The concept of social responsibility has been considered in education and moral development,20 civic engagement,21 community service,22 sustainable development,23 and within the corporate sector and business ethics.24 However, reference to social responsibility in dentistry has been made usually without a clear explanation of the concept or its application by dentists. We know that the few dentists who attend to the needs of frail elders in residential care struggle to balance financial cost with accessibility of care,25 but we know little about how most other dentists think about and struggle with their social responsibilities.
This article reports on the opinions that emerged during open-ended interviews with thirty-four participants (dentists, dental educators, and/or administrators and officials of dental public health programs in Canada and the United States) about the social responsibility of dental practitioners, especially relating to dental care for socioeconomically disadvantaged persons. We are reporting here on findings related to economics and professionalism that influenced how the participants think about social responsibility in dentistry.
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Methods |
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We selected arbitrarily thirty-four participants (twenty-two from Canada and twelve from the United States; six were women) from a range of backgrounds and senior positions in organized dentistry (n=10), dental education (n=15), and public health (n=9). The selection process was based on the principle of maximum variation to obtain as broad a range of views as possible about social responsibility in dentistry.32 With approval from the Behavioral Research Ethics Board of the University of British Columbia, letters describing the research and the purpose of the interview were sent to thirty-five potential participants who in our opinion were likely to help explain the range of views on social responsibility among dentists in North America. One person refused to participate.
One of the authors (SD) conducted all of the interviews and was assisted with the analysis by the other authors. An interview guide (Table 1
) served as a prompt to initiate discussion on various topics during the interviews, while the interviewer took a critical stance to constructively challenge and clarify the discussions during each interview.33 All of the interviews were audiotaped and transcribed verbatim for analysis. Moreover, each interview was analyzed in sequence, so that information from one interview could inform the course of the discussions during the next in keeping with the usual conduct of interviews during an inductive exploration.34 Each interview in sequence was subjected to an iterative process of coding to identify and group related narratives and quotations. The groupings provided the basis for emergent themes. The themes and their related dimensions were supported contextually by the sets of narratives from which quotations were selected for this article to illustrate and explain the background and scope of each theme. Information from the interviews became obviously repetitive or saturated between the thirtieth and thirty-fourth interviews, indicating that additional interviews were unlikely to yield new information.34
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Results |
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). Each theme is intersected by two dimensions: on the x-axis by "the individual and collective notions of social responsibility"; and on the y-axis by "the acceptance and challenge of the status quo" in the way dentistry is structured. Narratives dealing with the individual and collective notions of social responsibility revolved around the question of locus of responsibility—whether an individual dentist, the dental profession, or society as a whole is primarily responsible for the care of socioeconomically disadvantaged persons unable to access dental care. These narratives were then situated within accounts of whether responsibility for care could be achieved within the status quo of dental practice or would require radical changes to the current structure and provision of dentistry. The four themes and two dimensions provide an insight into conflicting views on who is socially responsible for ensuring equitable access to dental care, the implications for human rights, and whether the current structure for delivering service is meeting the needs of vulnerable populations.
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, yet economics dominated most of the interviews. For many, it was the bottom line against which other positions had to be justified. However, the boundaries between the four quadrants of the figure are permeable to accommodate the movement that most of the participants made among the four themes. A key part of the analysis centers on the tensions between different perspectives on social responsibility. As a result, the analysis focuses on how participants shift their position and the underlying premise of what they see as reasonable and justifiable in one instance, to an opposing position that seems equally reasonable and justifiable. Here we see the tension between the different constructs of social responsibility along with the constraints and challenges of accepted and dominant norms (i.e., the status quo) within dentistry. In the center of the four themes where the two axes intersect is the social responsibility to treat pain. It is the common ground of commitment voiced by participants when they spoke of patients in pain. It was referred to as an ethic that was held sacrosanct and considered a widely accepted code within dentistry. For the most part, taking patients out of pain overruled any personal justification and account of social responsibility. In this article we focus on the influence of economics within dentistry, with juxtaposing narratives from the theme of professionalism that served as a basis for responding to economic imperatives. Whilst there was general support for the idea of dentistry as an equitable and universally accessible service, most of the participants believed that the idea was restricted by the economics of running a dental practice. Each quotation in this report is identified by indicating the participant as a Canadian (C) or an American (A), followed by their primary role as a dental educator (DE), practitioner (P), or administrator/official in a dental public health program (AD).
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Dentistry as a Business |
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As such, the delivery of oral health care was perceived as subject to economic exploitation because there was "a tendency for care to be delivered as defined by insurance plans and for patients to sometimes be encouraged to have care because it’s covered" (C-P). Similar concerns were expressed about the six-month checkup as a regular source of income when "manipulating the rate of recall could have a very, very strong impact on their bottom line" (C-P). Concern was raised also about the "monetarization of medicine . . . and the kind of dental care and health care that’s delivered becoming extraordinarily dictated by what is profitable" (A-DE). Dentistry was also regarded as a profession that "many people choose . . . because of the living standard it provides. . . . Some . . . do it exclusively for that, and . . . many . . . are probably also very interested in caring for patients, but they tie it into the requirement to also earn a high income" (C-P).
However, dentists who defined their work principally in terms of the business of dentistry were referred to by one participant (C-DE) as "the 7-series BMW guys," suggesting a very high standard of living without commensurate social concerns. Particularly severe criticism was leveled at some organizations representing dentists. For example,
"the financial, business side of the Dental Association crest is so important and generates so much funds that one would have a certain suspicion that the whole process is money-driven. What is the dental organization really all about? It’s about the dental trade! You want to talk about social consciousness, right? . . . Is social consciousness billable?" (A-DE)
As a means of reconciling this tension, others said they left private practice for public administration, education, or public health because of what they perceived to be an unwarranted emphasis on money over social responsibility when
"the goal [was] to weed out those who weren’t going to pay you well—and that was intolerable to me. [From] the five or six hundred patients I had, I remember only one or two [hundred] who had dental coverage, and so there was a tendency to restrict your practice to those who were quite well-off, and I found that that was not my life mission." (C-AD)
In all, the tension between the economics of practice and the desire to serve the public good was perceived as a powerful force influencing dentists today.
Privilege and the Social Contract of Professional Autonomy
Critics of the economic influence in North America invoked the virtues of professionalism to defend their position. They referred to the range of privileges accorded to the dental profession as an impetus for social responsibility. They spoke of the professional privilege of self-governance, self-determination, and the freedom to determine how the dental health care system is structured. This for some meant that dentists were obliged to consider their "social contract" as a "responsibility for having that privilege" because
"the social contract is most explicit around those kinds of professions where a society says we will set you apart, we will grant you these unique privileges, we will let you be self-governing, and in return you will meet our needs. We have responsibility to the public. We have the privilege of autonomy because of that contract. Quite clearly we’re not servicing that obligation to the full extent. There are huge segments of the population that don’t have access to acceptable health services and I’m not sure [that] the profession’s too concerned about that." (C-DE)
There was a sense that dentistry "fights hard to protect its professional privileges but fails to uphold its obligation to society," mainly because it does not acknowledge the obligations and implications of professionalism. Another participant also worried that, without due attention to social responsibility, dentistry risks losing its professional privileges even though
"a lot of people think it is a God-given right, and they don’t realize it’s this fragile! And if the public at large perceive dentists’ sole purpose simply to make money, then they’ll say that maybe these guys shouldn’t be self-regulated any more because they are just money-making machines and why should we treat them differently?" (C-DE)
Similarly, another participant portrayed dentistry as "an elitist profession [attending to people who] have the means to go and they have the orientation to go, and it’s a very high [socioeconomic class] kind of activity, so you kinda get caught up in that; that’s what it’s all about" (C-DE).
Other participants criticized dentists as market-oriented professionals, catering primarily to consumer demand and concerned less with altruism and social responsibility in relation to professional obligations around addressing oral health disparities. The premise that dentists have the freedom to choose how they establish and run their practice was questioned by the view that
"if you’re gonna be a priest you gotta take all the parishioners; and if you’re going to be a teacher you’ve gotta take the unwashed as well as the middle class kids, right? If you’re going to be a physician . . . in a hospital you’re gonna get drunks and people who shoot each other, and . . . old folks. A physician in private practice will get the elderly, the unemployed, and the poor. [But], not in dentistry! [Is there] any other profession . . . where you can sort of say, ‘Well, I’ll screen out or only treat the kinds of or types of people that I want’?" (C-DE)
As a result, some participants insisted that a socially responsible dentist is someone imbued with trust, possessing expert knowledge and skill, and with social privileges, but that privileges should only be "granted because of the professional promise that practitioners make to use their knowledge and skill in the interests of those whom they serve" (A-DE). One participant explained with some concern that
"with [a] license to a monopoly comes the responsibility and an understanding that this will be better for everybody because you have this specialized knowledge you are going to apply . . . in the public interest . . . and we will let you do that as a restricted group precisely because you will benefit the whole of the society. Well, I think that’s largely ignored." (A-AD)
Private Enterprise Versus the Public Good
The answer to this dilemma between professional obligations and economic imperatives resided in a belief by some participants that the market is, in fact, a reasonable and fair arbiter of how social responsibility can be achieved. While proponents of the market system did not deny the importance of social responsibility, one participant argued that it would be unfair to "ask the [dental] profession to donate services [because] no [other] profession is asked to do this [and] without governments taking a role in this I can’t see how it can develop" (C-P). Yet, there was also concern that governmental interference would compromise the existing market-based structure and was expressed with the opinion that
"the market usually works, so for people who can afford to pay for the services, it’s usually not a problem, because somehow or other it will balance out: the dentist can charge fees commensurate with what the market will allow. But when you have a situation where the reimbursement rates are going to be artificially constrained because government decides [the] level of reimbursement, then you have problems. . . . [Governments] cannot ignore market forces. . . . I think it’s unfair for the government . . . to basically absolve themselves of the responsibility and shift the burden to the providers, and say . . . that you will assume the social responsibility of providing care for people [in need]. . . . Should the dentist essentially subsidize the rest of the government and the entire population by providing this service at a lower, reduced fee? Or, should this be subsidized by the larger population? Should the population at large, the entire population, be responsible for this care or [for] providing levels of reimbursement that are more reasonable, not necessarily what the market would pay, but something that would be fair?" (A-P)
This argument was advanced further by the dismissive belief that "the public health community, for instance, will often suggest that the providers should give this care away! And that’s how they will define social responsibility" (A-P).
Shared Responsibilities
Within the context of shared responsibility, patients who were financially poor also had a responsibility to contribute to their own well-being:
"I don’t believe in giving away care to someone unless they are physically, mentally disadvantaged and they can’t pay for it. Now, for those who are just poor, I’d be more than willing to provide them care in return for something, whether it is working on my car . . . [because] they have to assume some responsibility. . . . We’re not here to take care of the poor without some return from them. [They] can’t just ride the system." (A-P)
On the other hand, relinquishing care to a public system was rejected by some because it was inefficient in contrast to the marketplace where "dentistry has a very widespread private system, which some will argue very persuasively . . . is a very efficient system, and therefore we don’t need particularly to change that" (C-P). At the extreme, one participant represented the opinions of a few others by stating,
"I’d have trouble with the sense that we are lacking in social responsibility if these people aren’t taken care of. I don’t see that as social responsibility. The dentist’s responsibility is to society, and social responsibility infers responsibility for society. It could be taken as a definition [for dentists] to conduct themselves ethically, to provide treatment at the appropriate level, to conduct his financial affairs with patients at the appropriate level, to be an upstanding member of society. Ethically, [you have] to deal with pain and that is expected. . . . I don’t think it’s a dentist’s responsibility to help these people retain their teeth when the treatment is being done not for pain. . . . I don’t think that’s his responsibility to do that for nothing. I do believe very much that fee-for-service means proper remuneration and society is prepared to pay a laborer to dig a ditch, or a school teacher to teach a school or etc., etc." (A-P)
Limits of Responsibility
Everyone held the view that dentists have a duty to alleviate pain and that "nobody should be in pain" (C-DE). There was a general sense that this is a responsibility of all dentists without exception, even if it meant forgoing payment:
"You do have the ethical social responsibility to take people out of pain and try to remove disease, but not to do a whole lot more than that. If somebody comes to me in pain and says I can’t pay, then I’m not going think about money. . . . I’ll say, ‘Let’s take care of this and we’ll talk about that later.’" (A-P)
Anything more than alleviating pain, however, was considered by some a luxury for those who cannot afford it. Those who argued that the profession was not ethically obligated to do more than alleviate pain pointed to the lack of guidance from the codes of ethics within dentistry, which are "really only about professional ethics in the conduct of business . . . you don’t advertise and all that" (A-DE), and recognition that it is unwise to "leave that thing to the individual to make the decisions on, but the profession has got to have an ethical standard, and that’s where the slippage has occurred in the last twenty years" (C-DE).
Too Much Social Responsibility
A frequently articulated caveat that appeared within a number of interviews was that one should be careful not to have "too much social responsibility," usually within the context of an anxiety of "going broke," which provided justification against treating patients who could not pay. Too much social responsibility was seen by some as risky for dentists who could become "destitute because of their good will" (C-P) and centered on tensions between one’s private, individual goals and aspirations while simultaneously acting in the interest of others. Indeed, one participant advised that
"the golden rule [is] to look at it like this: if you found yourself in a situation where you were not able to afford care and needed care, you’d be very happy if somebody provided that care, so put yourself in that context as much as you reasonably can, [but] bear in mind that you’ve got to pay your freight, [which is] . . . a nice short way to sum up the kind of responsibility that I think people should be providing." (C-P)
Someone else suggested that dentistry needed to reexamine its social orientation in a market-based system and that there were limits when
"it isn’t like a religious order where life is one of total self-denial in working for the greater good. Well, we don’t quite want to go that far left do we? So, there has to be a middle position. And one thing you would like dentists to do . . . is to always put the interest of the patient first. We are too much to the right!" (C-DE)
However, the effort that organized dentistry made to keep out of the Canadian publicly funded health care system prompted the following query and angst:
"Why did [dentistry] not get into Medicare? [Because] the dental profession went ballistic! They essentially torpedoed that recommendation of bringing dental care into Medicare. The Premier comes down to the Canadian Dental Association meeting and stands up and says that ‘I’m here to announce that there will be no children’s dental care program in this province,’ and the audience stood up and applauded! We will applaud the fact that kids in the province will go neglected!" (C-DE)
Balancing Social and Fiscal Responsibilities
Some argued that a balance between social and fiscal responsibility was essential, provided it did not compromise the dentist’s living standards: "to generate enough income for my health care practice to pay for my office, to pay for my staff, [and] to provide me and my family with an income" (C-P). Yet others could not accept the status quo as the right thing because as one participant who eventually left private practice to work in a public dental health clinic explained:
"I came from a very high profile dental office and my job was to sell dentistry. I was given an imaging machine and I booked time with patients and I sold them crowns, veneers, and high-end dentistry. I did this for 18 years. I took a lot of courses . . . where you were taught how to sell dentistry . . . but it bothered me when I went home at night. Was I really selling things that people needed or was I making them want something for the benefit of the practice? I got paid a lot of money, I got to travel, I got bonuses, but it just didn’t fit after a long time. I was hired [in a public health clinic] to set up the dental practice and I’ve been here 8 years and it has been a real eye-opener for me. I work very hard and I have used some of my marketing knowledge and a lot of my business sense in setting this up; and I have great support from all the people who work here; and I go home and sleep well at night! It is a great feeling to give back and I think that is what was missing." (C-AD)
The above quote speaks to those participants who saw the need for wholeness in personal and professional integrity, suggesting that without such consistency the individual is short-changed in conscience (and perhaps even sleep).
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Discussion |
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One the one hand, there was a belief that social responsibility in dentistry is dominated by economic imperatives and that dental health care systems are influenced strongly by corporate-like organizational and institutional structures that have a negative impact on the policies and practices directing access to care. Yet, despite the highly critical stance on dentistry as commerce, there was practical recognition of the inevitable and necessary influence of economic realities on dental practice. Those participants who objected to commercialization in dentistry considered it a violation of professional obligations and privileges. They were critical of the image of dentists as commercial entrepreneurs who are primarily businesspersons and secondarily health care providers. A market-oriented health care system, they claimed, ignored professional obligations by introducing attitudes dominated by profit and favoring wealthier patients and those with dental insurance. The marketplace is, they contend, an inappropriate influence on the delivery of health care, which they considered a social good and a fundamental right of everyone. Participants who focused on professionalism highlighted the privileges of self-governance along with the accompanying obligation to serve the welfare of everyone and not just those who are socioeconomically advantaged.
Other participants, however, argued strongly that it was naïve to ignore or even subjugate the role of fiscal responsibility. They did not deny professional issues relating to equity and accessibility, but they believed in acknowledging without guilt the realities of practicing within a free market system, which, they assert, serves effectively as a fair arbiter offering equal opportunity to all. As such, the market is an acceptable vehicle for the efficient and reasonable delivery of health care. Furthermore, the proponents of the market system placed the locus of social responsibility not primarily on the dental profession but more directly on government-administered welfare and other public services for disadvantaged people.
As an inductive inquiry into the concept of social responsibility in dentistry, our study provides insight into the challenges facing the dental profession today. Overall, there emerged from the interviews a strong sense of the need for a reasonable balance between social and fiscal responsibilities. We were reminded that professional obligations and privileges demand that dentists make reasonable efforts to extend their services to all segments of society regardless of economic status. Nevertheless, the provision of oral health care for the poor, the aged, and the disabled, we were told, could not be addressed without managing the economic realities of dental practice. What we heard reflects the opinions not only of the participants but also of society. As one participant stated bluntly, "It’s a consumer society. . . . You can’t take a general trend in society and isolate it and say it doesn’t impact on a professional person." So, in this regard, we believe that our findings represent views that are widely held, at least in North America.
Those who provide care to disadvantaged populations have identified similar challenges35 and remind us that the issue of economics and access to oral health care has not yet been dealt with sufficiently in our society.3,25,36–42 Most societies expect dentists and other health care workers to place a high priority on society’s welfare, a belief that is at the core of most debates on health care and distributive justice.3,43 Theoretically, the concept of social responsibility is influenced by a range of viewpoints (recipient, provider, society) and subject to multiple influences (political, professional, economic, philosophical), all of which surfaced in our study. Our enquiry has helped to expose many of the realities of oral health care, not from the theoretical perspectives that have dominated most previous discussions on this topic, but from the opinions of thoughtful people who have wrestled seriously with the messiness and complexities of human relations in contemporary society.
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Implications for Dental Education |
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Are the students willing to learn about the realities of poverty, homelessness, disability, illiteracy, or ethnic diversity? Can they do so on a more than theoretical basis, accepting and appreciating these patients first as individuals and trying to decrease some of the barriers to care and to oral health? If they are able to demonstrate these qualities during dental school, will they continue to do so as practitioners after becoming immersed in operating a business?1
If the next generation of dentists is to be socially responsive within an increasingly materialistic society, dental education will need to demonstrate that there is "no intrinsic conflict between doing well and doing good."44 Educators will need to seek creative and relevant ways to develop and nurture common humanistic values and a general concern for human welfare.45,46 Students will need learning opportunities that enable them to experience the plight of vulnerable populations,47 so they can realize the social value of health as a common societal concern.48 Students who experience the prevalence of social inequalities in health are more likely to want to address disparities49 and more likely to realize why society recognizes and accords dentistry "a special social, moral, and political status as a profession."35 The value of social responsibility springs forth from here. It is tied to a social conscience, and it connotes an ethic of care and trust beyond individualism and private interests.
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Footnotes |
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This study was supported by a grant from the Social Sciences and Humanities Research Council of Canada, the Canadian Dental Hygienist Association Research Award, and the British Columbia Health Research Foundation. The protocol for the study was approved by the Behavioural Research Ethics Board of the University of British Columbia.
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REFERENCES |
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