Balancing commercial, personal and ethical demands in dentistry can be a challenge.
We leave traces on the things we touch. As a result of a range of popular television crime dramas, we are no strangers to the concept of fingerprint identification as a means of establishing who was where and what they did.
Fingerprinting has a surprisingly long history; the Ancient Babylonians recorded in clay the ‘prints’ of arrested felons. In the modern era, since the 1890s fingerprints have been used in evidence to tie an individual to a place or an action (interestingly, one of the first cases that turned on fingerprint evidence, that of Henri Scheffer in France in 1902, involved a murder on the premises of a dentist). The point is that the marks we leave can cause us trouble.
Our ‘ethical fingerprints’ also leave marks on what we touch. As well as potentially causing problems for us, they can cause trouble for our patients too.
An ethical framework
Ethics can be thought of as the framework of principles accepted by an individual or a group as guiding acceptable, expected conduct. It is a complex area involving the concepts of conscience, belief systems, right and wrong, and codes of behaviour. We may do our best to behave ethically but we are all human. Sometimes people do the ‘wrong’ thing through self-interest, convenience, pressure, or succumbing to temptation. Circumstances can also lead to an individual doing a bad thing for what seems like a good reason. We have all seen (and enjoyed) films where the ‘baddies’ get their comeuppance as a result of the ‘goodie’ doing something that is not merely ethically questionable, but is just downright bad – but somehow, we don’t mind this because it seems okay ‘under the circumstances’.
So it is possible to recognise something as ‘bad’, while at the same time excusing or even condoning it. From this, it is not too much of a stretch to suggest that given the right circumstances we are all capable of straying. Is it more moral to observe the rules or to help a loved one in need? Does it depend? This is the stuff of ethical dilemmas, which often involve choices that are not simple.
In clinical practice there is an expectation that we will put our patients’ best interests first, but does that mean sacrificing our own? As a business a practice needs to stay solvent, and it is in nobody’s interests if the practice is not run in a sustainable fashion. Dentistry straddles a tricky fault line. There is a need to combine effective healthcare with a commercially efficient operation. The demands of these two potentially conflicting drivers can create an intense ethical pressure on the clinician.
Commerce versus ethics
In the commercial field, goods and services can be thought of as falling into three categories: search; experience; and, credence. ‘Search’ purchases are those where a consumer makes the purchase based upon the known usefulness of the item, e.g., a car or a kettle. ‘Experience’ purchases are, as the name suggests, based upon previous knowledge and exposure to that good or service, e.g., a meal or hair appointment. ‘Credence’ purchases are where the consumer has limited understanding of the details or benefit of what is recommended, and has to rely upon the advice of the technical expert. This ‘information asymmetry’ makes the consumer reliant upon trusting the expert.
This may be good for the expert but with such settings there is the risk of temptation to provide less than ideal recommendations. A faulty computer, for example, might not need quite as much work as has been suggested, and the consumer is at the mercy of the integrity of the provider.
In the dental setting it can sometimes manifest as either under-treatment, where the patient really requires an intervention that is complex, time-consuming, or technically challenging, but only receives much simpler treatment, or over-treatment, where the intervention suggested is more than the situation really warrants. Where one party has the upper hand in terms of information, there can be a temptation to act in his or her own interest. A practitioner keeping a business afloat can be torn between putting patient interests first and the demands of running a business successfully. There can be a conflict between the interests of the parties, which needs to be recognised.
Beware of distorting factors
There are ‘distorting factors’ at play within ethical decision-making. These can include imperatives to hit certain targets, to upsell, to increase throughput or concentrate on high-value treatments. Working at a loss will obviously be unsustainable for any business but commercial viability should not come at the cost of ethical sacrifice as there are risks for both patients and clinicians.
One risk is from raised expectations and the patient not having the full picture regarding options. Credence involves trust and the information asymmetry mentioned above can create circumstances where patient choice can be distorted.
The public is hugely influenced by advertising and marketing. There are ever-increasing expectations around ‘aesthetic’ dentistry. Some patients feel that this will have transformative effects and improve not just their smile but their opportunities, life choices and popularity. Impressive as your dentistry might be, meeting these sorts of aims is a bit of a tall order. Although you may not want to deflate their dreams, it is important to manage patient expectations with very clear communications. What we know is that failure in communication is a predominant factor in the vast majority of dental complaints and claims.
A particular risk from the demands brought to the practice by patients is that of patient-led care with a focus on high-value treatment. With a willing consumer, the provider of credence purchases can easily, and inadvertently, move into the realm of over-selling, over-promising and over-treatment. The combination of wanting to accommodate a patient’s wishes, stretching our technical skills and needing to pay the bills can be a powerful mix. It can lead to going along with, or even encouraging, unwise patient choices. The result can be beautifully executed over-treatment or a ‘disappointment gap’ between expectation and delivery. Dentists are subject to the realities of business, but need active ethical awareness to eliminate behavioural bias and be aware of hidden temptations.
Keeping it ethical
So how does a clinician keep their fingerprints ethical? Start by asking yourself what is driving a clinical decision. Is it clinical need, the patient, you, the practice or financial pressures? Are expectations realistic in terms of treatment outcomes, comparative benefits and your own abilities? Is what is proposed a good thing, being done for the right reason, and is this the best option for this patient at this time? When discussing treatment, stop to consider if the advice presented is accurate and fair, if alternatives, risks and benefits have been presented clearly, and that you are satisfied that what is proposed is within your ability, in the best interests of the patient, and is what you would want for yourself.
Our ethical fingerprints reflect our behaviour and choices. Behaviour is susceptible to the pressure of circumstances and none of us are immune to temptation. The risk of our decisions being distorted by various pressures can be reduced simply by recognising this.
Dr Martin Foster
BDS MPH DipHSM
Martin is Dentolegal Consultant at Dental Protection