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The Need for Dental Ethicists and the Promise of Universal Patient Acceptance: Response to Richard Masella’s "Renewing Professionalism in Dental Education"

Key words: professionalism, commercialism, markets, dental ethics, universal patient acceptance, systems ethics, professional promises, public-professional partnerships

	Abstract

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Richard Masella’s "Renewing Professionalism in Dental Education: Overcoming the Market Environment" reveals why professionalism is nearly dead in America; it also shows the good of commerce and the excesses of commercialism in the market. More importantly, it collects and summarizes most of the relevant forms of education currently available to teach professionalism and professional ethics in dentistry; it then briefly examines whether those forms of education are used and if they are effective. Masella also asks some key challenging questions. His select and limited references lead to deeper studies about the nature and definition of professionalism and how it might be learned and presented. His suggestions for renewing professionalism are minimal; this sets the stage for proposing and selecting other ideas that need attention and development. Some of those ideas and suggestions, such as competition and collaboration, four types of dentistry, understanding two conflicting meanings of desire and need, and universal patient acceptance were recently explored in a workshop, "Professional Promises: Hopes and Gaps in Access to Oral Health Care" (procedings published in the November 2006 Journal of Dental Education), and were not yet available to Masella when his article was authored. His article, though, stimulates good discussion and action. Its data and substance show why, for example, dentistry needs to develop a core cadre of full-time practicing professional dental ethicists. Currently, there is only a small but very dedicated group of volunteers trying to meet our society’s need to bring new life to professionalism in dentistry and our market.

His references to the origin of the word "professionalism" provide insight into dentistry’s early involvement in the evaluation and influence of commercialism on oral health.² The word modification "ism" often means an overemphasis: commercialism and materialism are common examples. "Isms" can also reveal the worth of something hidden or balance another "ism." Any "ism" can be overused if and when it begins to harm the people and society it should serve.

Professionalism emphasizes profession as a correction to commercialism, not to commerce or markets. It is built on, and prioritizes, professional ethics over personal self-interest, business and organizational systems, or any other ethic.

Masella’s article is clear, sequential, and well thought out. It was easy for me to like and admire. It takes a messy patch of systems and describes them in a linear fashion that helps us make sense of what we are talking about. Masella also shows why professionalism in America is nearly dead; at the same time, he accurately captures the goods and excesses of commercialism in our vibrant market. His discussion of select references hopefully will stimulate discussion within the dental community about the meaning of professionalism and how professionalism might be demonstrated in education and patient care and learned by both students and practitioners.

Learning about vibrant living organisms and social systems in a linear way is an important part of education.³ This type of learning is a lot, though, like cutting up a worm. When you put it back together, no matter how well the mess of pieces is organized, or how neat the stitches, it is still a dead worm.

Masella’s suggestions, then, set the stage for proposing and selecting other ideas about professionalism that also need attention and development. These perspectives are intended to stimulate useful discussion and, ultimately, actions for revitalizing professionalism in dentistry.

	The Need for Professional Dental Ethicists

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Masella’s data and commentary show why, for example, dentistry needs to develop a core cadre of full-time practicing-professional dental ethicists. Currently, there is only a small but dedicated group of individuals trying to meet our society’s need to bring new life to professionalism in dentistry and its place in the market. This small group of individuals represents only a band-aid, however, trying to cover a large systems ethics problem.^4–6

I believe nurturing professionals in dentistry, and professionalism within the market, requires a few professionals who are full-time, degreed, practicing dentists/ethicists. They need to converse in all forms of moral imagination.⁷ They need to be in discourse with the profession, within and with the market, and even within and with our larger culture. They need to actively nurture the core values of dentistry and nurture the unique, monopoly-like mission that dental professionalism, with its supporting public/professional partnerships, contributes to the market. In this way, the dental profession can better serve the greater needs of our professional community, our larger society, and our even broader culture. An additional cadre of dentists/ethicists would allow professionals to more effectively evaluate, and help influence, how the market system itself impacts the oral health of society.

	Patching Professions and Markets

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A vibrant living market is openly influenced by subsystems of commerce and social regulation; it is shaped by the living philosophical, religious, and economic imaginations and beliefs of our culture. Our trust in our current market system depends on our ability to challenge and remove any restraints to the free exchange of the ideas that influence and define the market.^8–10

In the terms of market language, Masella claims that the dental profession, and professionalism, must resist the self-interest inherent in the market. At the same time, professionals and the dental profession must remain collegial and collaborative. That is, each dental professional’s expertise is not his or her own, but is collegial. The formation of a dentist into the subtleties of daily ethical practice and proper patient relationships is not something anyone can do on his or her own; it takes a community of mentors and friends. To do this, then, the profession needs to retain the meaning and sense of the very terms it uses to articulate its core values, build its integrity, and fulfill its mission.

One approach to making sense of this is to collect and collate stories of living things, not in a linear pattern, but more like stitching patches together for a quilt. I will draw on a few patches to help further our considerations about professionalism and the market.^11–15

Masella’s article, in this light, becomes an important patch in this quilt. Tools for measuring professionalism in dentistry are few and rarely tested. Masella, though, has summarized our most promising efforts. Each paragraph draws from a deep background of theories, studies, and experiences from fields outside and inside of dentistry and brings them to the attention of our dental profession. They draw not only from quantitative and qualitative measurements, but also from experiential stories and cases. The importance of recognizing Masella’s experiential references as evidence, however, may be overlooked if our appeal to evidence is limited to the basic kinds of measurements useful in science and markets.^16–18

David Stern’s Measuring Medical Professionalism is a key reference for Masella’s article.¹⁹ Stern and his contributing authors offer a broader background, and more details, about the concepts and perspective summarized by Masella. Yet, even though Stern’s contribution applies to professionalism in both medicine and dentistry, Masella’s summary, with its quotes and words of wisdom, is more likely to attract and stimulate dental educators and practitioners; and these observations about dental professionalism constitute a significant contribution.²⁰ If Masella’s insights are fully grasped by the dental community, it would also contribute to the ongoing dialogue within dentistry about professionalism’s relationship with health care and our society. Both Masella and Stern are well aware that what they present is only summary material, but they are not afraid of presenting the needed measurement focus in ways that accept the eternal and/or nonmeasurables of professionalism’s base—ethics/morality.²¹

Charles Bertolami’s "Why Our Ethics Curricula Don’t Work" is another important reference for Masella and, therefore, another patch in our quilt.²² It too is a touchstone article for dentistry and the future of dental professionalism. By building on the kind of experience and evidence bases that Bertolami used to confront our existing efforts to promote and nurture professionalism in dental education, Masella has sparked new life into our very need to confront commercialism within our culture and renew professionalism in all of dentistry.

The richness of Masella’s material, unfortunately, also offers the most significant challenges. Responding both usefully and effectively to this powerful presentation, then, is not something that can be left only to a series of unrelated sound bites or words of wisdom.

Still, the many wonderful phrases that Masella uses within each of his paragraphs are covers to the deep wells of professionalism. Readers could and should uncover and expand upon them. Dentistry and its public partners should further develop and continue to raise our awareness that professionalism needs to be revitalized. Fortunately, though, because of Masella and dedicated individuals like him, future educators in dental ethics now have a valuable resource to do more than just raise awareness.

	Attention, Articulation, and Acceptance

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The limits, and sometimes harm, that result from just raising awareness are well known; the significance of teaching to articulation and reasoning has consistently been shown to motivate good action in ethics education. However, educational programs that provide mechanisms for students to engage in intellectual activities that require articulation and reasoning have rarely been implemented. Articulation and reasoning are a package that includes critical thinking skills and faith; it is not misguided values clarification. It must be seen in, and practiced by, mentors; it must also be seen in, relevant to, and integrated into the total educational structure. Articulation and reasoning are one key measurable in professional education that Masella and Stern reference.^23–26 Being able to articulate and reason about what it will take to renew professionalism, then, is the core material that professional ethicists have been developing. It is also one of the key tools for revitalizing professionalism, not just within individuals but within organizations and systems. Future students of dental ethics will find Masella’s article a valuable resource for expanding on the field of professionalism.

Economists talk about commerce and commercialism in different ways. Yet, without some sense of my basic understanding about the underpinnings of how commercialism works and perhaps dominates our current market, it will be difficult for me to express what steps I recommend to 1) help renew professionalism within the market and 2) show how renewing professionalism within dental education, and perhaps business, will contribute to a freer market. Given the nature of a market and the need to guard against restraints, a healthy market will not allow anyone, or any one particular influence, to overcome it for very long. Therefore the best that might be done, in the spirit of the title of Masella’s article, is to overcome some of the forces that restrain professionalism’s role within the market. Professional promises are the patch pieces, then, that hold our best hope for nurturing a healthier market—open and free discourse within a frame of systems ethics.^27–31 Serious professional ethics education in dentistry will give the profession the voice it needs in the marketplace.

Each of these mentioned patches is important to the full quilt of professionalism. A few of the smaller patches from an August 2005 workshop, "Professional Promises: Hopes and Gaps in Access to Oral Health Care," that explored ethical issues and dentistry’s professional responsibilities related to access to oral health care, however, can help further set the stage for proposing a few more ways to strengthen the professional-commercial relationship. Some examples of these key conceptual ethics tools are professional promises, acceptance, universal patient acceptance, the roles of articulation and reason in discourse to help identify and satisfy the two basic forms of needs and desires, systems ethics, and David Chambers’s four different types of dental care.^32–38 These concepts and others are discussed in a series of articles from the "Professional Promises" workshop published in the November 2006 Journal of Dental Education. Some of the key concepts articulated therein are briefly discussed in the following paragraphs.

None of these smaller patches can be fully discussed here. The idea of acceptance, however, is the core notion for framing and developing the "Professional Promises" workshop and deserves a brief comment. Acceptance is both an ethic and an act, often hidden as a core value, that focuses on how health practitioners first accept people as possible patients. It is basic to the discussion because both commercialism and professionalism build on the notion of acceptance to define their chief client and mission; they need to do this, however, in very different basic ways. The notion also gives basic meaning to our sense of natural and legal rights that help mediate these basic differences in missions and chief clients. It therefore shapes both the meaning and our understandings about human rights and property rights. The notion of patient acceptance, then, should draw our close attention.

Masella, as we all do, ultimately desires to advance professionalism’s rights position in the broadest sense of economy. That sense of economy, with its various notions, is experienced in our daily personal and business lives but is rarely analyzed; it is, though, continuously discussed and nurtured with scholastic rigor in philosophy and theology and is not limited by the competitive and cooperative partnership terms of markets, commerce, or commercialism. One example of this broader sense of economy is the "divine economy."^39–41 In these broader senses of economy, the language of war, such as segmentation, targeting, competition, compromise, tactics, and strategies, can be counterproductive. It is rather the language of acceptance, collaboration, healing, and community that is and needs to become the dominant terms and metaphors.^42–44

Masella, Stern, and Bertolami did not have the discourse resources from the "Professional Promises" workshop for their use. Nevertheless, as new as those concepts of discourse may be or as new as their uses may seem, they still represent conversations, notions, and realities as old as the profession, and for that matter, civilization itself. It is conversations, not just market talk, that make the world go around. Those conversations are not just legal, economic, cultural, or religious; rather, they add up to a patchwork story from all of them.

Dentistry, then, must develop a core cadre of full-time practicing professional dental/ethicists; the mission of these ethicists is to keep the professional codes and terms and the characteristics, core values, and missions they represent alive.^45,46 It is not something that can be purchased like a business product. It is not something that can be taken off and changed like a new coat. Currently, there is only a small but very dedicated group of individuals like Masella trying to meet our society’s need to bring new life to professionalism in dentistry and our market.^47,48

	Questions and Beginnings

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From where will our future dental ethicists come? What should they be and what should they do?

Perhaps the question we all need to ask ourselves is: do we seriously want to balance commercialism’s disadvantages, harms, bad outcomes, and the general sense of rights violations that come with an overemphasis on commercialism in our market and society? If so, the ethic of acceptance needs a closer look. The notion that every person should, at a minimum, be received at the table, to at least be listened to and attended to, captures the missing, or at least unarticulated, core reasoning needed to retain the freedom necessary for both markets and professions. Universal Patient Acceptance gives voice to the nature and practical application of that ethic within health professions; it does so in terms of a freely given promise that the health professions own, simply because of what they are and do. We in dentistry must embrace it. It balances our fundamental negative right to be left alone. Society must respect and support that, if it wants to keep our professions as a partner in shaping our culture.

	Acknowledgments

 
Special thanks to Carolyn Gray, David Ozar, Bruce Peltier, and the editors of the Journal of Dental Education for their review and comments in preparing this reaction. The final result, however, is my view.

	Footnotes

 
Dr. Patthoff is a general dentist in private practice in Martinsburg, West Virginia. He is the liaison of the American Society for Dental Ethics to the American College of Dentists and the American Dental Association and serves on the Ethics Committee of the American College of Dentists. Direct correspondence to him at 300 Foxcroft Ave., Martinsburg, WV 25401; 304-263-0411 phone; 304-263-3288 fax; dpatthoff{at}peoplepc.com.

	REFERENCES

Top Abstract The need for professional... Patching professions and markets Attention, articulation, and... Questions and Beginnings References

 

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