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8 The Ethical Principles and Obligations to Increasing Access Brian Dolan, Ph.D. University of California, San Francisco Concern over access to oral health care services may be articulated as a problem of professional ethics and moral responsibility. Dolan proposed three basic questions to provide a framework for considering the ethical principles and obligations to increasing access: what is the problem or who are you concerned about, what defines the basic standard of care, and whose responsibility is it to provide access to oral health care services? What is the problem? From a practitionerâs view point, the issue of access can be defined in many ways. First, as an economic problem, many professionals carry burdensome debt and cannot afford to provide voluntary services. In part, the use of other types of health care professionals to improve access has an economic basis but also raises questions of professional boundaries. Access may also be defined as a technological problem. For example, the Internet was envisioned as a breakthrough that would provide free knowledge to everybody, yet not every person has a computer to access that information, showing the unequal distribution of resources provides âfreeâ knowledge to only a select few segments of society. In a similar fashion, teledentistry is perceived as one solution to improve access to oral health care services for remote populations. However, teledentistry also raises ethical and legal 67
68 THE U.S. ORAL HEALTH WORKFORCE questions relating to jurisdiction and patientsâ preferences for interacting with health care professionals. In general, the question of access to care is usually conceptualized from the practitionerâs point of view (i.e., how professionals can offer services) rather than from the patientâs point of view (i.e., how are patients most comfortable in receiving these services). The biggest flaw with volunteer efforts is that the arrangements for and type of care provided are practitioner driven and not necessarily responsive to patient or population needs. (Mouradian, 2006) What Defines the Basic Standard of care? There is no standardized definition of oral health that can be used to determine if oral health needs have been met. The 2000 surgeon generalâs report states that oral health is more than healthy teeth, but might also i Ânclude the prevention of the self-consciousness and embarrassment that can ensue with poor appearance or the ability to speak, smile, taste, and chew, âthe essence of our humanityâ (HHS, 2000). Translating this prin- ciple in to a standard of care, however, is challenging due to the breadth of this concern as well as the need to consider the patientâs point of view on the importance of social functions. For example, ethnic and cultural backgrounds may shape oneâs definition of a good smile, and so desired outcomes may not be universal. Whose Responsibility is it to provide needed services? The main ethical concern in dentistry appears to be instilling a sense of moral responsibility to provide services that will increase access. In the early twentieth century, oral health was already seen as a gateway to gen- eral health, and the development of public health dentistry served in part as an economic good to rebuild trust between the dental profession and the public. Throughout the 1900s there were repeated expressions of the need to educate students about their professional responsibilities. In 2006, the Journal of Dental Education devoted a special issue to the ethics of access to oral health care services (Catalanotto et al., 2006) in which the argument is made that while many stakeholders might take it for granted that the health professions have an ethical responsibility to provide services to improve the health of the population, the general public may not share that view: I believe that most people in our society view the professional ethics of physicians or dentists in a much more limited way, namely, within the
OBLIGATIONS TO INCREASING ACCESS 69 context of the one-on-one relationship with their professional caregiver. But if I have a toothache and am without insurance and the means to pay for needed dental services, I believe most Americans, would not expect a dentist to feel obligated to take care of me. I would be grateful if the den- tist felt this way, but I would understand the provision of free services to be a matter of charity and not something that I have a right to, of âgoing above and beyond the call of duty,â and as a reflection of his or her own personal values rather than any kind of professional obligation required of all dentists everywhere. (OâToole, 2006) The best way to engage stakeholders in wider public health debates and to foster collaboration may be to begin at academic institutions, the point where all professional stakeholders are physically the closest together. However, this engagement should not simply place pressure upon students to serve, but should include demonstration by educators of how to work t Â ogether and navigate the health care system. Todayâs students are frustrated by the problems of the health care system that are beyond the skills they have acquired with technical training; their sense of moral responsibility to volunteer may become overwhelmed by feelings of helplessness. While fostering subspecialized expertise is necessary, schools also need to commit to raising the profile of discussions about shared responsibilities and to defining the place of all stakeholders in the social contract of health. Schools also need to do a better job in training students to see health care problems through the eyes of their patients. In addition, health care profes- sionals need to engage more with social scientists, historians, anthropolo- gists, and patients themselves to better understand the social and cultural beliefs and priorities of different populations in order to determine the types of interventions that have the greatest chance of success. Therefore, students need to better understand how science and society are interdepen- dent. Instead of focusing solely on scientific results, students need to learn more about how the context of a patientâs life (the community in which he or she lives) affects care. Conclusions The ethical questions that face the dental professions lie less with a diminished sense of moral responsibility to help the underserved and more with the need to provide education about how to engage in community service. Ethical debates need to move away from general propositions about social justice and toward the importance of community-focused education. In 1992, Beverly Entwistle considered the question, âAre we creating Âsocially responsible dental professionals?â, wondering if students were willing to learn about the reality of poverty, homelessness, disability,
70 THE U.S. ORAL HEALTH WORKFORCE illiteracy, and ethnic diversity (Entwistle, 1992). The importance of an ethi- cal framework to define professional responsibility endures. However, this responsibility might be better defined as a responsibility to provide dental students with innovative, interdisciplinary, and practical instruction on how to think about and interact with different populations in need. REACTION AND discussion One participant expressed concern about the mindset of dental students in which they are focused on scientific and technological issues as well as the ability of schools to fit societal-related issues into their curricula. Dolan remarked that one challenge may lie within the admissions process, which might consider including assessment of the individualâs commitment to community service. He added that schools need to create opportunities for students to be more socially active. In addition, Dolan stated that the need for sociological education is not solely the responsibility of dental schools, but should be included more at the undergraduate level. In response to a question about data collection during the admissions process (regarding an individualâs history of community service), Dolan expressed concern about trying to predict future behaviors based on previ- ous experience. He said that even though some students may not, based on their history, seem geared toward community service, opportunities should be provided that would allow that individual to learn about this potentially rewarding career opportunity. Dolan added that to foster more collabora- tion, professionals in the social sciences also need to learn more about the practical realities of the clinical health professions. One participant stated that students often have great commitment to social issues but lack demonstration of a similar commitment by their role models, the older generation of oral health professionals. Dolan agreed. The participant added that students who graduate with enormous debt may question why they should be committed to their communities if the profession as a whole is not embracing this commitment. Dolan also agreed with a participant that it is a breach of ethical principles and obligations for professionals to refuse to treat certain subsets of the population.