Ethics
The Ethical Responsibility of Professional Autonomy
Bruce Peltier, PhD, MBA
Copyright 2001 Journal of the California Dental Association.
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Dentistry has historically been practiced autonomously, and many dentists place a high value on professional independence. This article outlines the conceptual basis for professional autonomy and asserts that dentists can retain independence only by aligning values with patients and remaining trustworthy in the eyes of the public.
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Many dentists chose their profession because they could make a good living doing
well-respected work in an independent setting. Most ethics seminars at dental schools include at least one student comment like this: "Well, that’s not the way my father does it in his practice, and I’m going back home to work with him when I finish school." There is a long tradition of autonomous dental practice in the United States, and most dentists strongly favor independence.
This article makes the point that independence has its place and its price, but total independence is not feasible and may not be responsible. Future levels of professional autonomy for dentists will be determined, for the most part, by dentist behavior.
Background and Theory
Dentists thrive on professional autonomy. Autonomy, in this context, refers to the capacity of dentists to decide, for themselves, how to practice. When they are autonomous, they choose their practice location, and they rent or build offices that please them and fit their practice philosophy (which they also choose). They purchase equipment that makes sense to them. They hire whom they see fit and see patients they choose. They select the materials and techniques to be used. They decide whether to perform root canals, extractions of third molars, and esthetic dentistry. They establish office policies that make sense to them, and they work the days and hours that they pick, given their goals and perceptions of market realities. Most dentists don’t report to a boss. They don’t even have to cope with a board of directors, as do CEOs. In this rosy (and admittedly overstated) scenario, dentists are at the top of the professional autonomy heap.
Professional autonomy, however, is not a "given," and it does not exist in a vacuum. Dentists have watched the recent decline of professional autonomy in other professions, including medicine. There are threats lurking for dentists as well.
Professionalism
Dentists, like most people, throw the word professional around without a clear view of what it means and what is involved. Usually, people use the concept to try to get others to conform. "Professional" to many people means "formal." If you are professional, you wear a certain kind of clothing, you use a certain kind of speech, or you follow certain rules of established behavior. You don’t spit or swear. But this is a misunderstanding of the concept of professional. A more useful definition includes the following:1
1. Practitioners have an uncommon and important expertise.
2. Practitioners are organized.
3. Practitioners practice autonomously.
4. Practitioners have a special service obligation.
In this model, professional autonomy derives from public permission. Dentists are autonomous because citizens permit it, and the public manages dentist autonomy through the regulatory actions of a state board. As long as dentists take care of people, their autonomy is permitted and endorsed by the public. When dentists abandon their special service obligation, their autonomy is restricted via regulations, examinations, license revocation, and other board actions. Professional autonomy implies obligation. There is an active relationship between the privilege and the duty.
Care and Commerce
Dentists and others who provide direct health care treatments face a special challenge. They must coordinate care and business, and this can be difficult and confusing because of the conflicting assumptions at the basis of each. The delivery of excellent, patient-centered care in the context of a successful business may be the most challenging aspect of the dentist’s professional life.2
Alvin Rosenblum reviewed economic theory in this journal in March and observed that the central ethical duty of a corporation is to return profit to shareholders and stakeholders.3 Publicly held companies do not have the luxury to make decisions that diminish the bottom line. The commercial premise is competitive, and the players understand the rules. Businesses compete, and they are always seeking something called the sustainable competitive advantage. They state their intention to compete, and they talk themselves into liking it. They don’t only compete with each other; they compete with the consumer. When a consumer enters a store to make a purchase, he or she understands the competitive relationship as it applies to the customer. Each party competes to get the best deal he or she can get. The consumer is unabashedly trying to get as much product as possible for the lowest price, while the store owner is trying to get as much money as possible while giving as little product as he or she must. Everybody knows the rules, and most play by them. Customers know that they should carefully evaluate the product and the situation. They study, compare, and shop. Even though both parties are polite, customers do not expect sellers to look after their interests. Customers must do that for themselves; and in industries where trust is most lacking (e.g., retail automotive), customers can be extremely diligent and even wary.
The arrangement in dental health care is quite different. Since patients are not able to adequately evaluate alternatives, they must rely on the dentist to help them choose. The basic relationship is cooperative. Dentists help patients make optimal choices by providing them with essential information and honest opinions. Dentists look out for the patients’ interests, not just their own; and patients trust them to do just that. Patients know that they are in a poor position to adequately evaluate the situation (especially if they are in pain or an emergent crisis), so they put their faith in the good will of the dentist. Dentists, on the other hand, make the interests of patients central to their practice, and they do not use their knowledge and experience against patients. They take care of patients and, in return, make an excellent living.
There are many examples or indicators of the essential difference between the commercial view and the ethics of care. In the commercial arena, trade secrets are closely guarded. Most dentists, however, would share a new technique that they have developed. That’s what professional journals are for. Dentists don’t spy on each other to try to steal their knowledge. Knowledge is shared for the benefit of patients. Dentists don’t cold-call patients; they don’t "slam" them on the telephone at dinnertime, as telecommunications companies sometimes do; they don’t offer finder’s fees or kickbacks for referrals; and they don’t snooker the patients of other dentists. They don’t even criticize other dentists. In fact, written codes discourage dentists from making public claims that their service is superior to the service provided by others.4
Dentists have a fiduciary relationship to patients, and that is the basis for professional autonomy. As long as dentists can be trusted to take care of their patients, they will be left to practice as they see fit.
Nine Decision Factors
Unfortunately (or fortunately, depending upon one’s point of view), the behavior and decisions of dentists have been subjected to progressively greater scrutiny and regulation over the past decade or so. Eve Cuny and others in this issue discuss examples of recent new regulations for dentists, including rules for infection control, disposal of amalgam, and others related to Americans with disabilities, sexual harassment, and child and elder abuse reporting.
These rules, imposed by others, are not the only external factors that must be considered by the dentist, however. Dentistry has never really been the isolated technical endeavor that some sentimentalists might imagine. The thoughtful dentist has always realized that there are many complex factors, aside from technical dental considerations, that affect the decision process. Nine such factors are shown in Figure 1. Here is a brief summary of those nine influences.
Normative principles. These core moral values provide a cognitive map for difficult dentist decisions. They represent collectively assumed norms and are prescriptive. These principles are extremely useful in the day-to-day decision process and include veracity, (patient) autonomy, justice, reparation, beneficence, and non-maleficence, among several others.5 Actions are chosen with regard to their conformity to the spirit of these principles.
Ethics codes. The ADA, CDA, and other organized dentistry groups publish guidelines that represent their aspirational view of how dentists should behave. These codes help dentists understand what colleagues think are the best practices. When these practices are universally followed, laws are pretty much unnecessary.
The law. State legislators, on behalf of citizens (and lobbyists, to be frank), craft and pass laws that bureaucrats translate into enforceable rules and regulations. In California, these rules make up the Dental Practice Act;6 and they represent the bottom line, the lowest level of care and behavior tolerated by regulators. These regulators and the rules they create have patients as their constituency. They protect the public from dentists.
Professional tradition. This is an invisible set of guidelines, often not articulated at all. Dentists follow tradition; and they are typically uncomfortable when it is violated, even when they can’t articulate the logic behind their discomfort. Tradition is the reason that virtually all dentists charge fees on a piecework basis, even though this may not, indeed, be universally optimal.
Standard of care. This is another invisible standard, and this one is not written, either. It exists in the collective minds of practitioners. This drives dental students crazy, as they try and try to figure it out. They should survey a couple of their favorite faculty members and ask several practitioners in their community for an opinion, then average the answers they get. This is likely to reveal the standard of care related to the matter at hand.
Organizational rules. These apply when a dentist works for another dentist or for a large organization, clinic, or dental school. That dentist must follow an additional set of rules established for organizational consistency, survival, and effectiveness. If a dentist can’t abide by these rules, he or she can’t work for the organization.
Dentist’s values. Certainly, these play a significant role in the overall tone of a practice, as well as in specific treatment decisions. A good dental practice reflects the best values of the dentist-owner. This is how the independent judgment of the dentist is expressed in actual practice. It is best when a dentist’s values parallel the prevailing values of patients in the local community.
Patient’s values. In a modern practice, especially one involving well-informed patients who actively take responsibility for their oral health, this variable must be incorporated into treatment and practice decisions. This is where the independence and autonomy of the patient is honored, and patients sense that they are well-cared-for when their values are respected.
Community values. This external factor is probably easy for dentists to accommodate when they are working in a community that is similar to the one they live in or grew up in. This becomes a more difficult variable when a dentist works in a community that is different from his or her own or when dentistry looks at underserved populations.
At least five of the decision influences listed above are external to the dentist and the profession (law, community values, patient values, rules of the organization where the dentist works, and, perhaps, normative principles). These factors represent sources of input that are imposed from outside, and they must be carefully considered by any thoughtful practitioner.
Squandering Trust and Autonomy
Trust in human relations is generally difficult to establish and easy to squander.7 When dentists move so fast they don’t hear the concerns of their patients, when they make "production" the central value of their practice, when older dentists teach younger dentists that the key to a good professional life is to "select" patients carefully and "dismiss" the rest, when patients come to the private conclusion that dentists are "money grubbers," if dentists rush to become plastic surgeons of the mouth, and if dentistry ignores large segments of the population on the assumption that individual dentists have no obligation to the underserved, there is a chance that the goodwill that exists between dentistry and the public could be eroded forever.
Summary and Key Concept
The central dynamic of the relationship between health care providers and patients is cooperation, where doctors look out for the interests of patients, and patients trust them to do so. Dentist autonomy is granted by the public in the form of minimal constraint by regulation or other external decision forces. For dentists to retain maximum professional independence, they must continue to meet the special service obligation expected by the public. In other words, as long as dentists are perceived to be trustworthy, to be looking after the interests of the public, they will be left alone to practice as they see fit. But, whenever the public perceives that dentists are not fulfilling their fiduciary responsibilities, they will be constrained in the form of regulations, license restrictions, additional requirements for specific continuing education, and the codification of treatment behavior through mandatory, standardized protocols.
Put simply, it is in the best interest of dentists (especially those desirous of autonomy and independence) to be trustworthy. This not only means that they need to behave well and take excellent care of patients themselves, but they must reach out, from time to time, and assert themselves to monitor and manage others in their profession.8 To retain maximum professional autonomy, dentists must get out in front of regulators by regulating themselves. It is in everyone’s best interest to do so because regulators respond to the most poorly behaved members of a profession by creating additional regulation for everyone.
Author
Bruce Peltier, PhD, MBA is a clinical psychologist and associate professor at the University of the Pacific School of Dentistry. He is course director of the ethics program and teaches communications skills to dental students. He maintains a management consulting practice in San Francisco.
References
1. Ozar D and Sokol D, Dental Ethics at Chairside. Mosby, St. Louis, 1994.
2. Nash D, A tension between two cultures … dentistry as a profession and dentistry as proprietary. J Dent Educ 58(4), 1994.
3. Rosenblum A, Ethics competencies in the business of dentistry. J Cal Dent Assoc 29 (3):235-40, March 2001.
4. American Dental Association, Principles of Ethics and Code of Professional Conduct, April 2000.
5. Beauchamp TL and Childress JF, Principles of Biomedical Ethics, 4th ed. Oxford University Press, NY, 1994.
6. Board of Dental Examiners, Dental Practice Act with Rules and Regulations. 1994.
7. Axelrod R, The Evolution of Cooperation. Basic Books, New York.
8. Peltier B, Reflection, introspection, and communication: A psychologist’s view of dental education. J Am Coll Dent 67 (4):33-8, Winter 2000.
To request a printed copy of this article, please contact/UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115, or bpeltier@uop.edu.
Figure 1. Nine Factors That Affect the Dentist’s Decision Process
