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Ethics Competencies in the Business of Dentistry

Alvin B. Rosenblum, DDS

Copyright 2001 Journal of the California Dental Association.

Ethics is the systematic study of human conduct examined in the light of moral values and principles. It is the most important competency in dentistry, in business, and in life. Competency in ethics requires an understanding of its accepted principles, and such competency is the obligation of every dental professional.

On hearing that the Harvard School of Business was gifted $21 million to teach ethics, someone said, "Teaching ethics to business people is like taking up a collection among Christians to buy new lions." Is ethics in conflict with business, as this statement would imply? Does adherence to the discipline of ethics hamper the goals of business? Many feel the primary goal of a business is the generation of a profit, while the primary goal of a profession is provision of a service. If so, then the core values of the dental profession would be at odds with those of business. Ultimately, the moral conflicts faced by those of us who engage in both the profession of dentistry and the business of dentistry are always the responsibility of the individual. Competencies in ethics require an understanding of the discipline of ethics and its accepted principles. Such competency is the obligation of every individual professional.

An Ethics-Based View of Business

A single-minded view of business holds that wealth is built by the creative ability of people and is inherently compassionate. Adam Smith, the architect of capitalism and of the ideas that shaped the concept of private ownership and the free enterprise system,¹ is the foremost proponent of this optimistic contention. Smith, considered by most to be the first economist, wrote in the 18th century that the capitalist system of economy proposes to enrich both the individual and the state. He argued for capitalism with a conscience that was designed to enable people to gain revenue at least for subsistence, and that it would also supply the state with sufficient revenue to provide public services.

Adam Smith came to question issues of economic decision-making while a student of moral philosophy. He was concerned about how people made good moral judgments, and this led him to a concern about how good economic judgments were made. In his curiosity about how people made economic decisions, he looked at how they weighed their own self-interest against the interest of others. Smith believed that the competitive urge was ingrained in human nature, and he felt that a person’s passion to get ahead would be kept in check by competition. He wrote that people do the right thing most of the time and that conscience and people’s capacity for compassion is the force behind self-regulation. For more than two centuries, his work has been the best statement in defense of the fundamental principles of capitalism.

Any system has flaws, and the capitalism of Adam Smith is no exception. But despite any shortcomings, the world is increasingly embracing free enterprise and an open market economy. William E. Simon, when secretary of the U.S. Treasury, said, "Capitalism sets forth sure principles by which we can meet the moral and financial challenge of the 21st century."

In modern times, many economists and business gurus have argued for a more cooperative and ethical approach to business. Team building has come to the fore, and many argue for more collegiality. Where war with its winners and losers is often a metaphor for business, "game theory" is now in vogue. At Yale University, they have coined the word co-opetition² to describe the more cooperative competition that is being encouraged. In this vein, the founder of Amway has written a book titled Compassionate Capitalism.³ Some view this as an evolutionary process moving from the capitalism of exploitation to the capitalism of service.

Every man, as long as he does not violate the laws of Justice, is left perfectly free to pursue his own interest his own way, and to bring both his industry and capital into competition with those of any other man or order of men. -- Adam Smith

We are now experiencing the most dramatic change ever in the world’s economy. There is a greater focus on principle-centered business management⁴ as well as a heightened awareness that business must be respectful of people and the planet. Globalization is creating wealth and changing the politics of nations.

Business as an Unethical Force

An alternate view of business, which is equally single-minded, sees business as almost exclusively motivated by greed. It is not difficult to conjure up a view of business that recalls the days of the robber barons, child labor, and gangs of thugs hired by large companies to break strikes and keep workers in line. It was a time of ruthless, greedy, uncaring capitalists, who wouldn’t allow ethics to affect the bottom line. Today we need only watch the evening news to see the tobacco company CEOs lie to us about the dangers of cigarette smoking; insider trading skewing market values; and corporate decisions leading to polluted rivers, poisoned air, and ruined lives. We have to wonder what the decision-makers at Bridgestone/Firestone and Ford were thinking in the recent tire failure tragedy. Was it the same kind of thought process that allowed GM to weigh the cost of litigation for the loss of life as a result of rear-end collision explosions against the cost of recalling vehicles? This view sees business profiting from human suffering and the destruction of the planet.

A Wall Street Journal survey of business managers⁵ concluded that ethics can impede a successful business career, and more than half of those surveyed said they would "bend the rules" to get ahead. One 50-year-old executive said, "I know of unethical acts at all levels of management. I have to do it in order to survive." According to the vice president of a Midwest company, "Opportunism, cleverness, and cunning are taught in business; and fairness and equity aren’t given equal time and importance." Caveat emptor -- let the buyer beware.

Famed economist Milton Friedman said, "There is only one social responsibility of business -- to use its resources and engage in activities designed to increase its profit without deception." Unfortunately, deception has become a common tool in business. So, in the admittedly single-minded negative view presented here, the nature of business is all about making the most profit and maintaining competitive advantage at almost any cost. In so doing, inherent adversarial relationships are created with both consumers and competitors.

If one views dentistry in this context, it is not difficult to cite the litany of wrongdoings in the profession performed as a result of greed, ignorance, and insensitivity to patients. The sacrifice of quality, overcharging, falsification of records, overtreatment, insurance fraud, and the like, are all at the expense of hard-won ethical standards.⁶ As Horatio says in Hamlet, "It takes no ghost come from the grave to tell us this"(that something is rotten in Denmark, etc.). We all know there are dentists among us who put their own wants ahead of patient needs. Each one of us must guard against even the subtlest violation of the principles of ethics (Table 1).

Dentistry as a Profession

Dentistry had its origins in early Greek medicine. Sacrifice of personal benefits for the benefit of the patient can be traced to that time.⁷ Its history is based on attitudes of benevolence and sympathy toward those it served. Dr. Pierre Fauchard, the French dentist of the early 18th century, set the standards for modern dentistry. He taught by word and deed that the sharing of knowledge and the minimization of the profit motive were necessary elements in the development of dentistry as a profession. It was generally accepted that the quality of patient care must never be sacrificed because of economic considerations.

It is widely accepted that dentistry is a respected healing, helping art and a learned profession that is more than a mere trade or business. An understanding of dental history helps us to appreciate the difference between a business and a profession.⁸ As professionals, dentists are holders of a public trust and must be accountable to that public both individually and collectively.⁹ As such, advancement of common social interests is a professional obligation.

Dental Practice as a Business

The interests of the dentist must also be served. One of those interests is economic success. It is intelligent to be concerned about remuneration, and that is a legitimate goal of a professional. Dentists are not expected to be motivated entirely by selfless goals.

By definition, a business can be any form of employment. It can be an occupation, a vocation, a trade, a calling or profession, or any combination thereof. In any such setting, the competencies of modern business, some of which are delineated in other articles in this journal issue, are unquestionably valuable and tend to be neutral from the perspective of ethics. These tools used properly are a means to increased profitability through efficiency, cost containment, and increased productivity without sacrificing the interest of the patient.

There are, however, numerous accepted business practices that are unacceptable, illegal, or frowned upon in dentistry. For example, in business, technical secrets are zealously guarded. Some businesses actively "spy" to acquire such secrets and to gain competitive advantage. Entirely acceptable in that competitive environment is the purchase or licensing of information and/or technology from competing companies. Random solicitation, "cold calling," is another commonplace practice. Finder’s fees, actively courting other’s clients/customers, and claims of superiority are also commonplace. These practices and others in business are almost universally considered counter-professional in dentistry.

Aggressive advertising, marketing, and solicitation are a hallmark of business. Dentistry banned such practices as early as 1866, and the stated purpose of that ban was concern for the public. It was feared that self-promotion by dentists would mislead patients. There was also a concern that such activities are demeaning to the dental profession. In 1960, dentistry officially declared advertising unacceptable. This ban was in effect until 1979 when despite the profession’s argument that advertising reduced dentistry to the level of an ordinary business and put patients at risk, the Federal Trade Commission and the courts influenced the removal of dentistry’s traditional prohibition. The FTC in essence declared that all learned professions are trades and subject to regulation as such. Since that time, competitive advertising has proliferated in dentistry. A recent court ruling has put the position of the FTC in jeopardy, perhaps once again distinguishing between the professions and other enterprises in the eyes of the law. Last September, the 9th Circuit Court ruled that regulation of dentist advertising was a benefit to consumers, and encourages rather than discourages competition.

The way dental practices have been promoted in the past two decades has presented an ethical dilemma. Many in the profession still consider advertising a questionable practice. They believe that such activity by dentists could rightly be viewed as an effort to motivate a "sale" and thus have dentistry viewed as a purely commercial enterprise and dental care viewed as a commodity, an article that is bought and sold.

Advertising is intended to create in the mind of the consumer the belief that there is a qualitative difference between the advertiser and others. In spite of clearly spelled out regulations against false and misleading statements in publications, such advertising abounds. Those promotional pieces that do not violate the regulations are generally punchy one-liners that render meaningless the complex issues about which patients must decide. Dentists are advertising in greater numbers. The result, according to renowned dental ethicist Dr. Clifton O. Dummett, "has been a growing tolerance of unproven claims by enterprising entrepreneurs and an encouragement of invidious comparisons among fellow professionals."

Dentistry and those it serves have benefited greatly by the advances in technology. We do, however, need to be aware of the potential for abuse. The intraoral camera has great educational and diagnostic value. Some dentists use the camera at times more for their own benefit than for that of their patients. Many serviceable restorations can be made to look frighteningly defective to a patient when magnified by a factor of 50 on a T.V. monitor. Computer imaging also has diagnostic and educational value but is abused when patients are influenced to undertake treatment with unattainable goals.

What the impact of information technology on dentistry will be is as yet unclear, but there is no question that it will play an ever-increasing role. E-commerce, the selling of goods and services over the Internet, will undoubtedly have an impact on the business of dentistry. Some dentists are already promoting themselves on Web pages that claim to educate patients. No matter that the prime purpose is the solicitation of patients. The "paperless office" and remote consultation with the transmission of patient X-rays and photographs present a threat to confidentiality. Despite the possibilities for abuse, data management has become a keystone of business success. There is no reason to believe it will have less impact on, or less benefit for, dental practices. We must nonetheless be aware of the potential risks posed by any new technology.

Much dental care is now procured, funded, and administered by business corporations. Third-party involvement in the provision of care has led to ethical quandaries. There is a perception that treatment of patients is determined as much by bureaucratic rules as by doctors’ judgment. Proponents of managed care argue that patients get "quality" care for less cost, and more patients can avail themselves of care. In opposition to that, it can be argued that an inherent conflict of interest exists when dentists are paid for patient care whether or not care is delivered. Nevertheless, the motivation behind third-party systems is economic. Cost containment and profit for business entities are essential goals. It is arguable whether the care of the patient is a goal of the same priority.

Conclusion

If teaching ethics to business people is like the purchase of more "lions," then is the teaching of ethics to dentists equally antithetical? In truth, neither is the case. In dentistry, as in business, there is certainly potential for wrongdoing. True, the rules of business are different from those of dentistry,¹⁰ but no legitimate enterprise is inherently unethical. The ethics failings in business and in dentistry are purely idiosyncratic, and both disciplines transcend the wrongdoings of the individuals who practice them.

Certainly the ethics challenges faced in various disciplines differ. Whether business people are more influenced by the pursuit of money and power than are dentists is debatable. As dentists, we must recognize that we have a fiduciary responsibility¹¹ and are held to higher standards by virtue of society’s trust and by our own established codes. In any event, the teaching of the discipline of ethics^12,13 is essential. Ultimately, we all must be measured against the basic universal moral principles. It is those principles that have come down to us through the wisdom of the ages that make up the complex discipline of ethics. Ethics is not simply right behavior. Rather it is the disciplined study of morality, a branch of philosophy called moral philosophy.

When we violate ethics principles, it is because we underestimate the value of doing the right thing. Doing the right thing pays off in the long run. The dentist who uses good business practices but does not put the exigencies of business ahead of patients’ interests, benefits over time. Growth of the practice through solid patient referrals, a sound reputation in the community, and greater peace of mind are just some of the rewards. So, in the long run, behaving ethically is good business.

This issue of the Journal is about competencies in the business of dental practice. Arguably the most important competency in dentistry, in business, and in life is ethics. It is ethics that provides a common language that allows humans to interact with mutual understanding. It provides a structure to explain our intuition. Ethics is the systematic study of human conduct examined in the light of moral values and principles.¹⁴ Applied professional ethics helps us relate the abstract principles of moral philosophy to practical problems. It is a competency for which we -- as dentists and as humans -- are obligated.

Author

Alvin B. Rosenblum, DDS, is an associate professor and clinical director of the Problem Based Learning Program at the University of Southern California School of Dentistry. He is a former member of the CDA’s Judicial Council and a fellow of the American College of Dentists. Dr. Rosenblum maintains a private practice in West Los Angeles.

References

1. Smith A, Wealth of Nations. Prometheus Books.

2. Nalebuff B, Brandenburger A, The right game: Use the game theory to shape strategy. Harvard Business Review, 1995.

3. DeVos R, Compassionate Capitalism. Plume Penguin,1994.

4. Chopra D, The Seven Spiritual Laws of Success. Amber-Allen, 1985.

5. Wall Street Journal, Sept. 8, 1987

6. Dummett CO, The influences of bioethics and history on the future of prosthodontics. Int J Prosth 1(3):241-4, 1988.

7. Hippocratic Treatises.

8. Dummett CO, Keynote address. May 1990 Sesquicentennial Baltimore College of Dental Surgery, Dental School University of Maryland.

9. Nash D, Ethics ... and the quest for excellence in the profession. Journal of Dental Education, 49:198-201, April 1985.

10. Peltier B, Practical ethics in the managed care era. J Cal Dent Assoc 24(8):29,1996.

11. Hasegawa, T. Dental ethics: Bridging theory and practice. Texas Dent J Sept 1992.

12. Beauchamp T, Principles of ethics. J Dent Ed 49(4):214-8, 1985

13. Odom J, Formal ethics instruction in dental education. J Dent Educ 46(9):553-57, 1982

14. Reich WT, ed, Encyclopedia of Bioethics, Vol I. New York Free Press, 1978.

To request a printed copy of this article, please contact, Alvin B. Rosenblum, DDS, 20257 Observation Drive, Topanga, CA 90290 or at rosenblu@hsc.usc.edu