Troubling Matters

In two of the past three years, the beginning of the new year has brought public focus to some nagging problems in the dental profession. In 1997, a Reader's Digest report brought to the attention of the public the matter of inconsistencies in treatment-planning and fee setting by dentists. This year, the TV newsmagazine "60 Minutes II" featured a story that highlighted the deaths of young children under sedation or general anesthesia procedures during treatment in the dental office.

It is too early to conclude what the impact of this most recent media report will be, although our initial belief is that the fears and concerns will be less far-reaching than the image problem faced by the profession in 1997. In our review, the report failed to establish that the lack of standards and safety precautions in the tragedies featured is an industry-wide problem. It also attempted to connect the lack of safety in the tragedies that were described to the lack of a specialty in dental anesthesia. However, interviews supported a general view that in at least a couple of the tragedies identified, there had been a lack of proper safety precautions employed as well as a lack of informed consent to the parents outlining the potential risks in the anesthesia/sedation procedures.

The thrust of such media reports encourages public support for stronger external regulation, which could ultimately result in removal of these procedures from the dental offices of competent, caring practitioners. It could also force unreasonably stringent educational requirements on well-qualified practitioners in the future.

The dilemma posed to the profession by these media reports is troubling. While a concerned profession cannot condone the actions of the negligence that contributed to the tragedies described, it is unfortunate that it must shoulder the negative public scrutiny that should more appropriately be borne by those who fail to fulfill their responsibilities of high public trust due to lack of judgment or skill. In contemporary society, it seems that the actions of a few will increasingly serve as the mechanism for public measurement of the profession's standards and image.

A frustrating aspect of these problems faced by the profession is that they are neither prevented nor resolved by regulations. The origin of so many of these problems is an ethical failure by the practitioner. Would a professional upholding the ethical principle of "doing no harm" ignore the necessity of employing appropriate safeguards and controls in a procedure involving risk to the patient? If it is argued that practitioner failures are matters of competence, does not the failure of the practitioner to undertake efforts to improve their skill and competence also violate the principle of doing no harm to patients entrusted to their care? The American Dental Association and California Dental Association have continually done a good job in establishing and supporting appropriate education and training requirements and safety measures in the best interests of the public. Yet there are those within the profession who ignore these standards by taking risks that are in violation of the public trust that the profession has been granted.

Another troubling matter that has been dogging the profession for some time has similar etiology. Recently, CDA leadership was challenged to consider a solution to the fraudulent claims filed by dentists with Denti-Cal and other indemnity programs in the state. Finding a solution to these abuses presents a considerable problem for two reasons. The organized profession is helpless to provide oversight without the data that identifies abusers, and second, it is likely that many in this group are not members of the organized profession and therefore are not bound to the principles of ethics or guidelines for professional conduct.

With certainty, there are also members of the organized profession in this category of risk-takers, who ignore the principles of ethics out of self-interest or ignorance. Even if the profession sets high standards and endeavors to monitor compliance, it is unable to oversee the compliance of these individuals because of the private nature of the business and patient treatment procedures employed inside individual dental practices. While peer review can assess the outcomes of many treatment procedures, it is not likely that either risk-taking practices that flaunt safety, or fraudulent business practices, will be subject to evaluation or scrutiny unless an adverse result comes to the attention of the public or profession.

That is why public opinion will eventually result in some form of continued competency assessment. That is troubling too, because the changes that will be required of the profession will come not only in response to competency issues, but primarily as a result of cumulative ethical shortcomings by dentists. That will be tragic in view of the importance that the dental profession has traditionally placed on professional principles of ethics.