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Are changes in the profession compromising dental ethics?

Feb. 1, 1996
In the first of two parts, members of Dental Economics` Editorial Board discuss the question of ethics.

In the first of two parts, members of Dental Economics` Editorial Board discuss the question of ethics.

Penny Elliott Anderson, Senior Editor

Are restrictive managed-care plans creating increasing problems with ethics and professionalism in dentistry? Are there other factors that are contributing to what many dentists perceive to be a decline of ethical standards in the profession? If ethics are being compromised, what can be done to deal with these problems?

These were the questions Dental Economics` Editorial Board tackled in a recent roundtable discussion that brought out a lot of emotion on the subject, as well as a wide range of opinions on causative factors and potential solutions.

Taking part in the discussion were outgoing Board Member Dr. Chris Kleber, a private practitioner in El Cajon, California, since 1983; Dr. Bette Robin, who has been in practice since 1985 and has gone from a very large practice to a small general practice in Claremont, California; Dr. Erich Heidenreich, in private practice in Marshall, Michigan, since 1988; Dr. Larry Cook, a general practitioner in Mariana, Florida, since 1980; Dr. Charles A. Vogel, a private practitioner with an emphasis on restorative and implant care, in practice in Springfield, Missouri, since 1966; and Dr. Andrew Schwenk, winner of DE`s recent-graduate position on the board, who is beginning his third year in private practice in Loves Park, Illinois. All serve five-year terms on the board, with the exception of the winner of the recent-graduate position, who serves a one-year term.

In his opening remarks, Dr. Kleber quoted from Rotarian and former Lt. Governor of New Mexico, Casey Luna, who defined ethics in a 1993 speech as "about how we think and the actions we take as a result . . . In the public sector, ethical behavior is about trying to make the right decision, often under difficult circumstances, and taking responsibility for your decisions."

Trying to make the right decision under difficult circumstances may be at the very crux of what all DE editorial board members perceive as a growing problem with ethics in the dental profession. However, their solutions to the problem varied greatly, as the discussion that follows illustrates:

Dr. Chris Kleber: Managed care equals managed costs. This scenario reduces choices that the dentist and the patient have for treatment. San Diego has been a very interesting arena to watch, because next to Minnesota, it is the most highly capitated area in the country and is a "Beta test site" for many new managed-care plans. Profit-driven decisions by government and industry have forced many practitioners to alter delivery of services to a lower standard clinically. With increased exposure to professional and contractual liability and third-party scrutiny, practitioners are increasingly asking, "Is it worth it to me to continue to practice in this manner?"

The "one fee covers everything" attitude of HMOs, PPOs and capitated plans creates false expectations of security that are realized when the patient needs or desires treatment and can`t have it. "Sorry, your coverage doesn`t pay for that. You have to pay for that yourself." This creates hostile feelings between doctor and patient, rather than patient and third party. Who loses? The patient, ultimately!

As for ethics in dentistry and what defines ethical behavior, I am a Rotarian and I believe that the Rotary International 4-Way Test of things we do, say and think provides a simple, workable guideline for answering questions of ethics. That test asks:

1. Is it the truth? (Focus on Facts)

2. Is it fair to all concerned? (Focus on Folks)

3. Will it build goodwill and better friendships? (Focus on the Field)

4. Will it be beneficial to all concerned? (Focus on the Future)

Dr. Bette Robin: I`ve gone full circle from a large practice to a small practice in Claremont, a small college town and also a geriatric community. There are 68 dentists in a town of about 27,000 in population, but I`m the first female dentist to practice in Claremont.

I made the transition to be able to do the kind of ethical, high-quality dentistry that I wanted to do. I think you have to get out from under all this overhead if you are going to work by yourself to be able to practice that way. I started this practice about a year and a half ago, and it`s fun.

I recently earned my law degree, and my goal is to combine dentistry with consulting on employment law and practice transitions for dentists. What I hope to do is to continue to practice one or two days a week and either take in a partner or sell part of my practice to allow me the time to do some of these other things.

I believe we should examine where we got our ethical values as dentists, besides from within ourselves. So, given my interest in legal issues, I decided to check to see if we are governed by any ethical rules as dentists. And, basically, I found out that we really aren`t governed by any rules, because the ADA`s Code of Ethics are suggestions for how we should behave, but mean absolutely nothing legally. They are guidelines only, because the ADA is a voluntary organization. So, if we don`t want to follow these guidelines, we don`t have to.

I also wondered if the profession has experienced an increase in complaints from the public about ethical issues. So, I looked into that quite a bit in detail, and talked to all levels of the ADA, the CDA and my local component society. They keep some degree of statistical information on this, though not extensive. But, to my surprise, there has not been an increase in complaints in the past 10 years.

Nearly everyone I talked to felt that there are increasing problems in the ethical arena, but evidently patients aren`t complaining or, if they are, they are not viewing the problems as ethical in nature. Most of the complaints currently on file have to do with false and misleading advertising. Com- plaints that involve dentists in managed-care plans have to do with misunderstandings in communication. For example, dentists don`t take the time to communicate clearly or the patient`s perception of their treatment outcome is different from the reality. Managed care doesn`t allow for time to explain treatment choices to the patient by the dentist.

All this leads me to believe patients are just changing dentists if there is an ethical problem out there or they are not expecting as much with managed-care programs. But they aren`t filing specific complaints about dentists` ethics to their state boards or the local or state dental societies.

Dr. Andrew Schwenk: I have been in private practice for three years in Loves Park, Illinois. I have never known practicing dentistry in an environment without managed-care plans. It is an evil knocking at my door and ringing my phone daily. None of us can do what we do, get paid 15-25 percent less and survive, no matter what costs you control.

Let`s say you gross $100,000 per year and have an average hourly production of $50 per hour. You decide to participate in a managed-care plan that discounts your fees by 15 percent. That reduces your annual gross income to $85,000, but if you still work the same number of weeks and hours per week, you reduce your average hourly production from $50 per hour to $42.50 an hour. To generate the same amount of revenue as you did before agreeing to participate in the managed-care plan, you would have to work 46 hours per week. If the program decreased your fees by 25 percent, then you must work 53 hours per week to generate the same $100,000 in income.

What does this have to do with ethics? I think too many dentists, especially young dentists, jump into these plans without thinking them through. I have heard about a dentist who participates in a number of different managed-care plans. One of the plans has a $1,000 de-ductible per patient, after which it pays the traditional 80 percent for Class II benefits and 50 percent for Class III and IV benefits. He claims he is forced to charge for unnecessary dentistry in order to meet the patient`s deductible and get insurance benefits for them. So, he will do a prophy and that`s what the patient will pay for, but he will send it in to the insurance company as scaling and root-planing to meet the deductible faster. He says this is in the patient`s best interest. He may be right about that, but to me, that is how he justifies fraud, which has criminal consequences. I cannot and will not allow my office to intentionally steal or falsify anything. But many do because the bills need to get paid.

Many of these programs claim to promote a high level of preventive care by creating a "maintenance mentality" within your patient population. But the problem is, we as dentists must accept the full financial burden of getting these patients to that level in the first place. If you are getting 180 new patients through the ABC Capitation Plan, that is 30 patients per month. At a capitation rate of $6.66 a month, that comes to about a $1,200 monthly check. How many of those patients could you afford to do a significant amount of restorative work on, with your hygienist getting about $600 of that $1,200, leaving you with $600 to pay the rest of your overhead and to provide these wonderful, new patients with all the oral health care they need?

As far as I`m concerned, these plans are structured to promote undertreatment. Once any treatment is rendered under these plans, profit immediately is affected in a negative way-exactly the opposite effect of fee-for-service dentistry.

Suppose we all tried our best to reduce overhead as much as we can (as if you already aren`t!). How much more could you lower it? Maybe 10 percent (very generous!), but that is 10 percent off of your current overhead, not gross production income. In my case, a 10 percent reduction in my current overhead would be only 4.8 percent.

Ultimately, there are some absolutes that cannot be compromised. These include the commitment to patient health and welfare, treating each patient equally, providing patients with the care they need and having practice principles based on traditional ethical and moral standards. Should we allow patients to be influenced toward these programs, without fully informing them of what is involved besides less out-of-pocket expense, then we will be the reapers of poor planting for our future ability to function as a business. Letting glitzy insurers stimulate employers with false realities and not getting directly involved is like allowing our landlords to determine when we will get electricity to run our compressors, dictating how we operate and when.

If we, as a profession, would bind together, disavow and disallow anything but what we want to accept as a profession to keep ourselves on the decision-making and decision-taking side, we would prevent any outside interference from violating the most sacred aspect of our profession, which is the doctor-patient relationship!

Dr. Larry Cook: I firmly believe that the enactment of the plans we are seeing take place in our profession is neither managed nor is it in any way a demonstration of caring. At the very best, managed-care plans can be called only the placement of systems that are a weak attempt, though extremely damaging to the dental professional, to control the cost of services. Managed care is a fee-controlling system, period. It has nothing to do with managing anything that I can see.

I wanted to start with some definitions to lay some basic groundwork. So I went to the dictionary and looked up the definition of "ethics." Web-ster`s defines it as "a branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of actions and the goodness and evil of motives."

Another part of the definition says it`s "the rules of conduct recognized in respect to a particular class;" i.e., in our case, the dental profession. I also decided to look up the word "professional." According to Webster`s, a professional is "a person who declares himself or herself to be skilled in and an expert of a learned body of knowledge and activity. The professional performs his or her skilled learning and expertise with expert correctness, facility and adeptness. The professional standard carries a degree or level of requirement, excellence or attainment."

I like these definitions coming out of Webster`s, but now I`m going to get a little more home-based. Some 15 years ago, I was very fortunate to meet Dr. L. D. Pankey, and now I spend some time teaching at his namesake, The Pankey Institute. I didn`t look up the definition of professionalism, because I like Dr. Pankey`s definition, which comes off a slide he frequently used in his lectures. Dr. Pankey said, "It [professionalism] is that quality of conduct which accompanies the use of superior knowledge, skill and judgment toward the benefit of another person or society, prior to any consideration of self-interest."

That really sounds altruistic, doesn`t it? But as you think through that definition very clearly and apply it at the heart level, it gives you a clear direction-some "back to absolutes."

Like Andrew, I really do believe there are some absolute rules of conduct of any profession that are mandated on us, that live today, in this year, to carry on. I think these principles are within the heart and mind of each of the individuals that collectively make up this profession. And, if we can`t and don`t hold on to them, I think we have lost the profession.

What`s a fair fee? If managed care is dictating controlling fees, what`s fair? This is what Dr. Pankey says, "A fair fee is that sum of money for which a dentist can perform his/her best service, of which he or she is capable of, and the patient will pay with gratitude and appreciation." That last part is very important to me. I practice in a small rural town in northwest Florida that thankfully was bypassed by most of the recent destruction caused by Hurricane Andrew. Building a relationship with my patients is very important to me. I call it relational; Chris calls it a partnership. But whatever you call it, when we lose that special relationship with the individual we are serving, I believe we are lost as a profession.

How can a patient and I make decisions about his or her oral health care unless we, first of all, take the time to establish a relationship together? All of the managed-care plans that I`ve seen have certain criteria that dictate a dentist would not be able to spend the time necessary to develop that partnership or that relationship with people.

A long time ago, a guy that preceded Dr. Pankey, Dr. Halley Smith of France, said "every dentist has the moral obligation to do the best he or she knows how and is capable of for every patient who presents himself or herself. Nothing less can be found acceptable." I call that an absolute requirement.

Since managed-care systems neither manage nor care for a particular entity, but rather deal with a system to control the cost of services, without concern for the management success of dental practices nor the ultimate care provided to the patient, who or what may be at risk?

When I run the numbers on these managed-care plans, there isn`t any way-and I don`t care what percentage of the practice it is-that it will not influence your decision-making along ethical lines; the ethical decisions that have to be made every, single day. With these plans, it`s very obvious that all the financial risk is being transferred to the dental professional.

As Andrew also pointed out, a dentist working for this type of arrangement is agreeing to work on a fixed-fee basis. On average, this is closer to a 20-30 percent reduction in fees rather than the 15 percent Andrew used in his example. For a dentist to maintain the same level of profit, the dentist must increase his or her volume of service by 400 percent.

What does this do to your lifestyle? Practicing seven days a week for long hours each day? Is that not an influence on ethical decision-making? The only way a dentist can accomplish such a level of profitability is to overtreat on a high-volume basis or charge for services that are not rendered, neither of which is ethical.

So tell me. Can a dentist participating in these programs provide the highest level of standard of care while being forced to increase his or her quantity of services 400 percent from prior acceptable levels? Is the over-riding sentiment in our profession that we should now relent and accept a significantly lower level of lifestyle and professional status in our chosen endeavor of life? Are we, as professionals, entering into these fee-controlling systems only to maintain a job? If so, why not lay bricks?

I like what Mike Schuster said: "Professionalism re-quires a commitment to excel and a dedication to high ideals. It means doing what is in the best interest of the patient first and foremost. It seeks to know the patient and help the patient seek the best treatment that is consistent with sound principles of dentistry. Professionals affirm the time-honored tradition of placing the welfare of the patient above all other considerations."

The demands of our profession are commitment, excellence, absolute standards, highest ideals, patient first prior to self-interest, honorable daily conduct and a skillful application of our knowledge. If we allow an insurance company or managed-care system to pressure our ethical decision-making and if we no longer daily reaffirm commitment and excellence in our mode of practice conduct, can we truly continue to call ourselves a profession?

Is there such a thing as trust for a profession to hold on to? I say yes, there is! And, it`s a whole lot more than just the technical decision-making of what we do. It`s relational. It`s doing things for another human being.

Can we aspire to a level of professionalism that says, "Even if I might lose here, I`m going to do it for the betterment of you." Can we do that on a daily basis? That`s a tough question! Under managed care, I think we are influenced to do it in a wrong way. How can we continue to be a hallmark profession and live up to the profession`s ideals if we allow this to consume us and our pa-tients? I don`t think we can!

Dr. Erich Heidenreich: Let me preface my remarks by saying I think we`ve got a very, very good subject for this round-table and I don`t think it could be any more timely. I`ve been hearing more and more about ethical concerns lately, and I believe there is a crisis going on regarding ethics in dentistry. We all know that the outgoing president of the ADA, Dr. Richard W. D`Eustachio, has resigned from the Academy of General Dentistry because they dropped the requirement that AGD members must be members of the ADA. In an article in the ADA News, President D`Eustachio said one of the main reasons he was resigning was because, "I was appalled when I heard the delegates at the AGD meeting speak from the floor of the house and ask why they had to follow the ADA Code of Ethics and why the AGD didn`t develop one of its own."

If those and other statements constitute a call for unity, then I truly lack an understanding of the English language. There is a crisis in ethics and it`s the ethics of the decision of the AGD to remove its requirement to belong to the ADA, which prompted the ADA president to make his decision, and now they`re going back and forth with letters and really arguing that point. Where is our Code of Ethics? Where`s this cohesiveness that brings us all together and makes us a profession? If we don`t have a Code of Ethics, we don`t have a profession, because that`s the thing that brings us together. Whenever you start talking about organized dentistry, or dentistry in general, the thing that brings it all together is our Code of Ethics. So this is very, very important.

Looking back at the early days of our profession, it might seem as if we`ve lost our definition of what`s right and what`s wrong. I say we haven`t! Unethical dentists always have existed, even in the 1920s; but, because there are more dentists than a century ago, there also are more unethical ones. Percentage- wise, I bet it`s exactly the same.

Managed care is a part of the ethics problem, but it`s not all of it. We just can`t limit this discussion to managed care and its influence on ethics, although that probably is the main thing that has brought this concern about the future of our profession to the surface. The core difference in this mode of treatment centers on utilization, so the ethical question is, "Do fee-for-service dentists overtreat or do managed-care dentists undertreat?" And the answer on both counts is "yes, sometimes." But which is more dangerous to the patient? Certainly, both can lead to negative consequences, but would you rather have a crown placed on a tooth that may have survived with a large amalgam or would you rather risk fracturing it beyond repair? Which is going to do the patient more harm? Overtreating or undertreating?

There are all kinds of bad things that can happen from undertreatment and there are bad things that can happen from overtreatment, too. But which causes the greatest risk? A lot of incipient-carious lesions dictate observation rather than restoration, and yes, the ethics of which one to fill varies with all of us. You might fill an incipient carious lesion that I might keep an eye on for another six months.

The problem with managed care is that it becomes a matter of self-preservation instead of a decision of ethics. That`s the point at which managed care brings out unethical behavior; anything but minimum treatment takes money right out of the managed-care dentist`s pocket. Even if a dentist is ethical in his/her heart, managed care makes it difficult to practice his or her true beliefs, and nowhere is this more true than in a group practice or a franchise, where the junior associate must follow policies established by the practice owners.

So there`s no question in my mind that managed care and insurance, in general, have reduced the dentist`s ability to practice ethically and have had a great effect on the ethics crisis in dentistry. That`s a given. Nothing should force an ethical person into unethical behavior. Nothing! It would be better for that dentist to change occupations. If you have to cheat to win, it`s better not to play at all.

Dr. Charlie Vogel: I agree and I love everything that everyone has said today. I was born into dentistry. Dentistry has been a part of all 53 years of my life. My grandfather was a dentist and I really looked up to him and respected him. He started practicing in 1920, which is about the same time that L. D. Pankey started in practice.

My values and ethics actually go back a generation because I hold to the values and ethics that a 1920`s dentist like my grandfather had. In fact, if all dentists had the values and ethics of a dentist who started practice in 1920, I doubt that any PPO or any insurance company would be able to find anybody to work for them. Because that group of dentists with those ethics would have said, "Take it and go."

If ethics are an outgrowth of our beliefs and values, then all of us are going to have a certain amount of differences in our ethical codes. A 1994 survey conducted by the ADA Survey Center found that 80 percent of dentists are aware of the ADA Principles of Ethics and Code of Professional Conduct and that 67 percent had either a good or very good understanding of their ethical obligations under the code.

Understanding something on an intellectual level and then acting it out on a feeling level are two different things. Marketing people know that most consumers make their decisions on a feeling basis, not an intellectual basis. So, to educate dentists to be more ethical may not necessarily help, because they may intellectualize and know that that is the right thing to do, but when they act out their next event, they are going to do it on a feeling level. Studies also show that our values and ethics are pretty well fixed in us by the time we`re about 10 years old, so they are formed well before the dental-school experience, and our values only change if we have extremely emotionally-significant events in our lives.

I think we have to accept the fact that the current dental population is a mixture of all kinds of ethical standards. Based on that-and putting my own personal values aside-I also have to say that from what I have heard from the people in this room, everyone is in total denial of what is happening out there!

That same ADA survey showed that among the areas of most concern to dentists regarding ethical obligations, managed care topped the list, with 48 percent of dentists selecting it from several possible choices. Rounding out their concerns were criticism of other dentists` work (41 percent), quackery (34.2 percent), advertising (28.2 percent), use of auxiliary personnel (24.6 percent), referrals (15.9 percent), billing practices (14.7 percent) and patient selection (13.7 percent).

By the year 2000, 25 to 30 percent of the population base is going to be in managed-care insurance plans; that`s a given; it`s going to happen. You have to accept that this is going to happen, whether we as dentists like it or not. The patients in these plans are going to be served by somebody; if there are not enough independent-practice dentists to service them, the managed-care companies will hire or import their own dentists.

I`m not going to be one of those dentists faced with that problem. I`m retiring in 10 years. But a whole generation behind me and those to come will be faced with this problem, and that`s why I think we can`t really talk about how we improve individual ethics and professionalism without ac- knowledging the changing environment in which these dentists will practice.

Dr. Larry Cook: I`m not in a state of denial at all! I think there is a certain percentage of the population that will be served by managed care, whatever form that might take. I agree with you, there. What I disagree with you about is that we are talking about the ethics of the dental profession, rules of conduct, rightness and wrongness . . . and we`re talking about professionalism that`s always been held to and whether or not those individuals who predominantly practice in that mode can live up to those ideals on a daily basis. That`s the question; not whether the world in which dentists will be practicing is going to change. What I`m saying is that the majority of these plans are a direct affront to the ethical standards, to the ethical conduct, to the high ideals of tradition to which the profession always has been held.

Dr. Charlie Vogel: Could you accept that we will allow the profession to divide, as Avrom King predicted almost 15 years ago, into three different groups, of which you will be in one group, and you will have the option to choose as your patients the group of people who have like values, and then you will allow these two other professional groups, one which we might call the marketing and advertising group (the dentist who has a high Yellow-Page profile) and the other group, which will be under some kind of program in which the dentists are directed to perform services based on contract criteria, such as a managed-care group? When Avrom suggested these groupings, the term "managed care" didn`t exist and the example he gave was the military dentist. That was the closest thing he had to relate this to.

Dr. Andrew Schwenk: Charlie, I disagree. Separating or dividing the central core of practice and practical applications of clinical dentistry is not mutually exclusive to each other. In fact, our overriding decisions for successful practice are based entirely on how we care for all patrons, regardless of their socio-economic background. We are obligated to treat the poorest of the poor the same as the richest of the rich if we follow the basic rules of care-that is, we are caregivers to those who cannot care for themselves. However, this does not "entitle" anyone to treatment of choice; but, rather, treatment of need. We can care for everyone as long as those being cared for have a general understanding that there are several alternatives to nearly every treatment. Chevy Luminas are nice cars, but are not Cadillacs. They ride well, provide transportation, safety and even comfort, but they are not Cadillacs."

Dr. Larry Cook: There are societal forces at work that I agree with you on, Charlie, and I think tiers already exist today. I`m not denying it, but what I am doing is putting up a standard, putting something on a pedestal and saying what`s right and what`s wrong. It`s what ethics is by definition. I challenge everybody in Tier III to say, "What are my ethics?" I`m not saying that they all are going to leave these managed-care systems; I don`t know whether they will or not.

I believe that medicine is right on the verge, if not already over the waterfall, of dying as a profession. I just don`t want to see that happen to the dental profession.

Dr. Charlie Vogel: I would like to help those of you in this room to accept that death, and, with that death, allow us to give birth to something else. That birth could include a fee-for-service dentistry organization, an advertising group of dentists organization and still another dental organization based on managed care. You, Larry, as well as the other dentists in this room, would become a member of the fee-for-service group and you`ll have the same Code of Ethics as other dentists in this group and you`ll be extremely happy.

Dr. Chris Kleber: But will I share a common bond with the gentlemen or lady down the street in a different tier of dentistry who also claims to practice what I practice? Would there be a sign on that person`s wall saying, "I am not a member of Tier III dentistry; this is Tier 1 dentistry." So we would have McDonald`s and then we would have Chez Paul up on top, and the patients decide whether they want a basic hamburger from McDonald`s or a gourmet meal from Chez Paul`s.

Dr. Charlie Vogel: Correct! We not only would do that, but we would participate in educating the public to know the differences among the three groups, because now they don`t know the difference.

Dr. Larry Cook: How could you do that? Since when did the profession as a whole ever vote to do some mass education via the media? We don`t do it!

Dr. Charlie Vogel: Part of our charge today was to not only discuss if ethical problems are increasing, but to suggest potential solutions. The problem is that the public is uneducated about this.

Dr. Chris Kleber: But I honestly believe most people want to build a partnership with their doctors. Certain people will thrive under a patriarchal model, which is what managed care is, but most patients and dentists want a partnership model.

I believe the solution to increasing problems has to be dealt with in two areas: the society/patient and the dentist. The society/patient must make a paradigm shift away from a patriarchal model that is perpetuated by a governmental and insurance bureaucracy. This controlling model creates dependency on a third party for responsibility, process and result.

A partnership model in dentistry continues to be a workable model for the future. Bob Barkley, DDS and L.D. Pankey, DDS, developed the model of codiscovery and co-ownership of one`s health. Partnership means that each of us at every level is responsible (Response + able = Choice) to define our own values and desired results. Once we define our results, we choose appropriate actions to achieve them.

When a patient moves away from being a limited, entitled participant to being an unlimited co-creator of his/her own results, he or she is healthier and enrolled in the prevention of future disease. The patient shifts from a "Just fix what is broken, Doc" (or being told we only fix what is broken!) model to "What can we do to prevent my problem from getting worse?" The patient is given a choice of what is best for him/her in terms he/she can understand.

There is room in the partnership model for third-party reimbursement, if it is simple for the patient to understand and limited to basic-disease control and prevention. This is direct reimbursement from a schedule of benefits. The dentist is faced with a double-edged sword of the rising costs of operating a business and decreased reimbursement from a third-party payer.

How can a dentist think that a 20 percent reduction of fees in an HMO, PPO or cap plan can pass the Rotarian "4-Way Test" of ethics without "cutting corners" in clinical care? I am concerned that many dentists are continuing to make business and patient-care decisions that are based on fear-fear of liability, fear of financial loss and regulatory reprisal for noncompliance with OSHA, the Americans With Disabilities Act of 1990, etc. Fear keeps the dentist`s perception of limited choices alive.

"Do no harm" and "caring for the patient" raise serious ethical questions in the minds of dentists and patients when limited, financially-driven options are in effect. Socialized dental programs in Canada, England and Sweden are being seriously challenged as to their long-term effectiveness. Why do we think that we can do it any better?

Dentistry is different from medicine. I believe that we can say "no" to any outside party that indirectly dictates a compromise in ethics. I believe that we can look our patients in the eyes and say, "Yes, I will give you my best, and we need your understanding, dollars and active participation to do it. For you (the patient) are the one who ultimately benefits from your efforts. You are responsible."

With the rise of available financing from outside sources, patients can afford to seek the level of dental health that is most appropriate for them. I believe that the investment in prevention and quality dentistry that "looks good" and "lasts a long time" is what the patient wants when he/she understands the benefits. Where else can they spend $600 for a product (for example, a gold crown) that they will use every day and which will likely last for 30-40 years?

Dr. Bette Robin: I believe the feeling many of us have about a growing lack of ethics is a symptom of the general moral and ethical decline of the society in which we live. The breakdown of the nuclear family, the loss of community bonding, lead to the corresponding lack of personal responsibility.

Our reliance on government in general in all aspects of our lives, which Chris describes as patriarchal, has caused a lot of our problems. No longer do we bond together as families, as husband and wife or as communities to take care of our own. The constant denial of responsibility for our own family`s actions allows us to place the blame elsewhere. It`s always "someone else`s fault."

This attitude, unfortunately, but predictably, has spilled over into dentistry. As dentists, we no longer know and feel responsible for our patients as people. We are not intimately involved in their lives as we used to be. The problem of connecting with our patients is increased by the patient-load demands of managed care.

I really believe we have the luxury of staying fee-for-service. The solution is to stop insurance and governmental intervention into our practices and our lives. Stop allowing insurance maximums or managed-care programs to dictate treatment. Let patients be responsible for their own dental bills and bill their own insurance if they have insurance coverage. (Continued)

The choice is ours. We must uphold the highest values and ethics in the treatment of all of our patients and not let any insurance company, regardless of the type of plan, control our profession and our treatment plans.

We either have to have an independent relationship with patients or participate in these managed-care plans. The choice we make governs our ethics, the type of dentistry we do, etc. Dentistry isn`t such a group of high-fee services, as opposed to medical services, that most people can`t afford it. I think we are in a position to say, "We don`t have to do this."

Dr. Charlie Vogel: As I said before, I think we must accept that the current dentist population has a mixture of ethical standards. Adding ethics testing to the dental-school admissions process would be of little value in the short run and it would be detrimental in the long run. There is a need for dentists with different value systems to treat the patients from various backgrounds. If all practitioners had the values/ethics of a dentist that started to practice in 1920, I doubt that the PPOs, HMOs, etc., would find anyone to work for them. But perhaps the 1990`s dentist, with a different set of values and a different set of beliefs, will be able to work under the guidelines of a PPO or HMO without feeling the inner strife that someone with the values of a 1920s-era dentist would feel.

Here are six things I think we could do. First of all, I think we have to accept the changes. These changes are out there and they are going to happen, whether we as a group here, the ADA, etc., say it isn`t going to happen, it`s still going to happen. Until we accept the fact that changes are occurring, change holds us prisoners.

Secondly, we need to redefine the new rules that the changes have brought about. The rules of the game, for example, that said we protected and sometimes even overprotected the small minority of dentists who have operated immorally and unethically by covering up for them. That leads to my third point, which is to continue strongly to self-police our own industry-maybe even harder than we ever have. I`m not talking about burning these people at the stake, but getting some help for them, much as we try to do for dentists with a drinking or drug problem. We need to figure out what`s causing the "stinkin` thinkin` " in their lives and get them the help they need. Just ignoring these dentists isn`t going to help anyone. We`ve got to have a group within our profession that goes out and seeks out those who, because of a lack of ethics or a lack of skills, are not practicing good dentistry and we`ve got to deal with them.

Then we need to educate the public that they have a place to go if the ethics of the dentist they are going to seems to be inappropriate. Patients need to know that most states do have some sort of state board or policing organization. We need to let them know they can contact these organizations and they will investigate their complaints. I think we owe it to our patients to really examine their concerns about their dental treatment and not just slough it off and basically say to the patient, "We`re just here to make it all look good and we`re going to just cover up for any mistake a dentist might have made."

I also think it is important to educate the public about the fact that many of their employers are demanding that insurers provide dental plans with stringent cost controls, and that quality of care will continue to deteriorate as long as these plans are strictly price-driven. They need to understand that many of these plans achieve short-term cost savings at the expense of their employees` long-term dental health.

My sixth point-and the one that comes from my heart-is, I think we dentists who would like to see the profession maintain the highest level of ethical standards need to band together to keep from being controlled by insurance companies or big government. We also should not sign any contract with anyone other than the patients to whom we have pledged to keep their well-being foremost in our minds when rendering our services. It is my feeling that the person coming in for care must come first. Intervention by any other outside source denies our ability to serve.

Next month, in the second part of their roundtable on ethics, Editorial Board members discuss the pros and cons of a national marketing campaign and how it might increase busyness and, with increased business, a return to higher professional ethics.

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Dental Economics` Editorial Board Members, from the left: Doctors Charles A. Vogel, Chris Kleber, Bette Robin, Andrew Schwenk, Erich Heidenreich, Larry Cook.

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