Dr ELEANOR O’HIGGINS answers questions from the Journal about ethics and dentistry.
What sets a profession apart from other groupings in society?
A profession is identified by four interrelated hallmarks.
- A common body of knowledge which characterises the unique domain of expertise of the profession: this body of knowledge has to be updated continually through ongoing professional education.
- A registration system which offers a licence to practice the profession or admission into the profession: the register is maintained by a recognised body, such as the Dental Council, and is usually based on fulfilment of stipulated educational requirements accredited by the competent authority, the Council. The attainment of educational standards must be from a recognised institution. Therefore, the integrity of the registration system depends on verification that the educational institutions where members obtained their qualifications are recognised in the profession nationally and where there is agreement internationally.
- Service of the public good: in contrast to commercial interests, professionals are expected to serve the public benefit, so professional values and standards are placed ahead of individual interests. In particular, the patient’s or client’s interests (the convention is to refer to recipients of professionals as ‘clients’, whilst in health related professions, such recipients are referred to as ‘patients’) take precedence over those of the professional. The Dental Council Code presents various elements of acting in the public interest, both through relationships with and the welfare of individual patients, as well as responsibilities to the community as a whole.
- A code of ethics/conduct: this is a shared code which stipulates a higher level set of principles or ethical tenets, and expected standards of conduct that reflect the stipulated principles. Professional codes go beyond what is legal. A code is of no use unless it is enforced, so the certifying body may monitor adherence to the code by members, and impose sanctions when expected standards are not maintained, up to expulsion from the register, even if the individual has not been found legally liable for any transgression. The classical example of a breach of ethics in dentistry and medicine is overtreatment.
How does judgment play a role in a profession?
Professionalism depends on more than possession of knowledge and clinical competence. It depends on the ability to apply that knowledge and competence appropriately, based on experience. Judgment relies on the integration of formal facts and tacit knowledge. Tacit knowledge may be seen as ‘unspoken knowledge that people draw on from within themselves: observations, ingrained habits, inspirations, hunches, and other forms of awareness that are typically not written down or codified, but that live in people’s minds and bodies’, defined by Ikujiro Nonaka, a Japanese guru in knowledge management. Therefore, good judgment is learned, but cannot be taught explicitly.
What ethical dilemmas are faced by business people, including health professionals who provide a service to patients, in relation to the idea of public good?
There are countless ethical dilemmas in both business and the professions, but I would like to mention one that is very important and common to both. This is the inequality in knowledge frequently found between sellers and buyers in business paralleled by inequality between professionals and clients. Thus, the client is highly dependent on the professional who could use his/her superior knowledge to mislead or take advantage of the client, e.g., a dentist recommending unnecessary treatments. In commercial transactions, this would correspond to the doctrine of caveat emptor – let the buyer beware. This was a doctrine that banks used when they gave out unsustainable loans to borrowers in the housing boom.
However, with professionals, it should be different. One would expect training on professional ethics to be a key part in the education and formation of dental students. Therefore, their pledge to act in the public interest and adhere to a code would prevent untrustworthy actions. It means that ethical behaviour does not have to be constantly enforced by law, which would be costly and largely impossible. Instead, we can reasonably expect that the members of the profession will instinctively do the right thing, even if they could get away with transgressions.
There is an understandable temptation for all of us to be swayed by self-interest as exemplified by more profitable treatment modalities over equally-effective, less-expensive interventions, or adopting a minimally invasive approach. The latter choices would make dental treatment more accessible to those in greatest need.
Why is a code of ethics or conduct so important for a profession?
It is not just important – it is a moral responsibility. As mentioned in response to the previous question, obedience to a professional code allows clients and the public generally to trust the members of the profession. This enhances the relationship between the professional and the client for the benefit of the client. Of course, the spirit as well as the letter of the code has to be upheld, just as law cannot in itself prescribe virtue, if people are determined to circumvent it. This is where a strong competent registration body is important in ensuring that the code is a living document to its members, not something to be got around.
What is your assessment of the Code of Professional Behaviour and Ethical Conduct published by the Dental Council of Ireland in February 2012?
It appears to be a helpful document covering the high level aspirations of the profession, as well as the expected standards of day-to-day behaviour of dentists in relation to various stakeholders, like clients, fellow practitioners, and the community. However, it is important that practitioners use it in combination with The Code of Practice pertaining to Public Relations and Communications, The Code of Practice Related to the Display of Private Fees in Dental Practices, and The Code of Practice Relating to Non-Surgical Cosmetic Procedures, as all of these codes cover interrelated ethical issues.
What is trust and what are the important components of trust?
Trust is a core concept in professional practice. When you trust someone, you allow yourself to be vulnerable to that individual, even when you have no way of monitoring or controlling him/her, as you believe s/he will act in your interests even when s/he could get away with it if s/he took advantage of you. In that sense, you are willing to take a risk by exposing your vulnerability.
We trust those whom we consider to be trustworthy. So, that raises the question of how, or when, we consider someone to be trustworthy. Trustworthiness depends on three necessary components. One is ability or competence, i.e., that the person is competent, has the knowledge to do the job, so a dentist who is properly registered with the Dental Council would be considered competent. Another component of trustworthiness is benevolence, so we believe that a professional is putting a patient’s real needs first. Then, integrity is a component of trustworthiness, the perception that the trustee adheres to a set of principles, consistent with the values and needs of the truster. This can be an issue of character. All three components of trustworthiness must be present for an individual to be trusted. So, I would not trust Mother Teresa to perform a tooth extraction on me, even if I were convinced of her benevolence and integrity.
Can you describe the relationship between risk and trust for a patient of a dentist?
Patients are able to trust dentists and put themselves into their hands when they believe the dentist is trustworthy, i.e., possesses all three components of trustworthiness. Competence would usually be ensured by the certification process. Belief of the patient in the benevolence and integrity of the dentist is usually built on a developing relationship, but before the patient visits a particular dentist, the benevolence and integrity of the dentist may be known to the prospective patient through word-of-mouth from other patient experiences and general reputation. Of course, nowadays, the internet and social media allow for speedy word-of-mouth reporting of experiences with particular professionals. Isn’t there a website called, ‘rate my dentist’? Of course, such websites are not always influenced by high-minded moral principles and are unfortunately open to abuse, so we have to be careful about trusting those websites themselves!
Why is integrity such an important concept for a profession?
Integrity and moral behaviour are inseparable. Integrity is a cornerstone of positive human interaction, especially where trust is necessary. Genuine relationships are based on integrity, and professions are built on authentic personal relationships with clients. Such relationships would not be possible without integrity on the part of the professional.
Isn’t integrity redundant in the modern world – and especially after the last 10 years in Ireland?
On the contrary – the last 10 years in Ireland have shown the disaster for society when there is a breakdown in integrity, so integrity is needed more than ever. This is what prompted President Higgins’ pursuit of an ethics theme this year. Whilst integrity may be difficult to achieve when there is so much cynicism about, we should continue to strive for it – and professions should lead the way. If they fail to do so, they leave themselves open to stricter regulation and all that implies.
Genuine relationships are based on integrity, and professions are built on authentic personal relationships with clients.
What observations would you make about the difference between clinical errors and moral errors in relation to dentistry?
There is very little scope for clinical errors in health matters. Nevertheless, they do occur, unfortunately, and usually cannot be helped. However, when there has been carelessness, or perverse decisions have been involved, these are moral issues. Also, moral fallout from technical errors may occur when there is a cover up, or when a legal case is fought tooth and nail in court, even when the fault is obvious, so people who are already victims of error are subjected to further unnecessary stress. This may, of course, be at the behest of insurance companies. It is interesting that in a recent settlement by a school and a hospital involving a rugby injury to a schoolboy, his mother was disappointed at the fact that neither party had apologised for their avoidable mistakes, which had ruined the boy’s life. Wouldn’t such an apology have been simple, honest, and helped to diminish rather than compound the damage caused?
What is your view, in terms of the ethics of the profession, of the advent of a lay majority on the Dental Council?
It is a great idea, so dentists can understand the perspectives of patients and the public, and the possible negative and positive effects of their profession, grounded in actual cases. A combination of lay and professionals on the Dental Council enables an assimilation of perspectives and a more open, informed, comprehensive view of issues of concern than dentists on their own could obtain, even with the best of goodwill. In fact, lay majorities are now a common feature in professional regulatory bodies. In my experience, having served on the Press Council, which comprises a lay majority, for two terms, I have experienced this kind of decision making firsthand and it works really well, especially when everyone is interested in the fairest outcome. It is important to note that, although there was often vigorous debate, there was no ‘them and us’ atmosphere on the Press Council, and never did the Council line up as press versus lay members on any issue during my time there.
Why is the use of disciplinary powers as important as their very existence?
If standards are to be taken seriously, they must be enforced, even if the vast majority of members are upstanding. Indeed, it would be ludicrous if those who failed to practice in an ethical manner were protected by the vast majority who do so.
Have you any observations on ethical issues faced by dentists (or healthcare professionals in general)?
As mentioned previously, dental and healthcare are of critical importance to patients and cannot be seen as a commodity. Since trust is so core, any actions that breach trust become ethical issues. These may range from matters to do with misinformation, medical negligence and professional misconduct, for example, when practitioners close ranks to protect fellow members who have obviously been guilty of breaches.
Based on your academic and professional observations, is Irish society becoming more or less ethical?
It is difficult to say – there is perhaps a greater awareness of ethics and wrongdoing, which would not have come to the fore in times past, when cover-ups and silence would have been the order of the day. I am thinking about issues like clerical child abuse and financial scandals. However, this is a small country where cosy relationships still hold considerable sway. Also, as a Canadian, I am surprised by the attitude often found in Ireland that refuses to acknowledge the responsibilities of citizens to contribute to social solidarity by paying for services such as water charges, taken for granted in most developed countries. Another characteristic I have encountered is the justification of antisocial acts such as tax evasion and fraudulent welfare claims as quite in order on the basis of oppression by the ‘system’, or ‘everyone else is doing it’.
Would you have any specific message for dental students that are about to graduate and enter the world of patient care?
It would be to take seriously all four pillars of professionalism, and to always live up to the need for trustworthiness. Any compromise of principles is usually impossible to reverse, and instead, the beginning of a slippery slope, (if I may use a cliché), so don’t fool yourself into believing that a small breach is just a once-off.
Is there any other comment or observation you would like to make in relation to ethics in dentistry?
If dentists put the interests of the patient first in all they do, not alone will they protect their patients’ interests, and themselves from medicolegal consequences, they will be able to experience true personal satisfaction from having lived up to the noble aspirations of their profession.