Dentistry as a Business in Tension with Dentistry as a Profession

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Dentistry as a Business in Tension with Dentistry
as a Profession
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The Concept of Profession is a Cultural Construct

• Culture is the collective, mutually shaping
  patterns of norms, values, assumptions, beliefs,
  standards, and attitudes that guide the behavior
  of individuals and groups, whether those groups
  be families, religions, races, geographic
  regions, nations, businesses, or professions.

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• Norms-what the culture understands as normal
  that which should occur naturally the cultures
  guiding rules or principles.
• Values-what the culture desires desires create
  purpose- purpose provides meaning.
• Assumptions-what the culture takes for granted
  what it presupposes, takes for granted.
• Beliefs-that in which the culture places its
  trust and confidence.
• Standards-the uniform referents of the culture
  the touchstones used in measuring and evaluating.
• Attitudes-the emotional intentions of the
  culture what it feels and wills.

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Culture and Ethics

• To describe differences between cultures is not
  necessarily to draw moral conclusions only to
  characterize differences.
• Of course, one can prefer the characteristics of
  one culture over another. Preferences are not
  (necessarily) morality.
• French/ChineseSocialism/Capitalism
  African/EuropeanMuslims/JewsProfession/Business
  

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The Culture of Dentistry As A Profession

• Norm - Oral health is a primary good an end in
  itself.
• Value - Care and concern for all people and their
  oral health.
• Assumption - Societal good
• Belief - Cooperation and reciprocity with society
  can result good for all.
• Standard - Justice/Fairness
• Attitude - Egalitarianism

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• Professions are organs contrived for the
  achievement of social ends rather than as bodies
  formed to stand together for the assertion of
  rights or the protection of interests and
  privileges of their members.
• The organizational component of the
  profession is explicitly meant to emphasize the
  advancement of common social interests through
  the professional association.
• Abraham Flexner U.S.
  Educator and Reformer of
  Medical Education
• 1915

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• The core criterion of a full fledged
  profession is that it must have means of ensuring
  that its competencies are put to socially
  responsible uses professionals are not
  capitalists, and they are certainly not
  independent proprietors or members of proprietary
  groups.
• Talcott Parsons, professor
• Harvard University
• Dean of American Sociology

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The Culture of Dentistry As A Business

• Norm - Oral health as a means
• Value - Entrepreneurial building a successful
  enterprise profits
• Assumption - Private good to be maximized
• Belief - Dentistry as a part of the free
  enterprise system
• Standard - Marketplace
• Attitude - Social Darwinism

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Tension Between Dentistry as a Profession and
Dentistry as a Business

• Dentistry has historically understood itself to
  be a profession (and continues to do so), and has
  laid claim to professional privileges. It has
  been understood to be focused primarily on
  serving the oral health needs of patients, with
  the financial gain derived from such being of a
  secondary nature cooperating with patients for
  the patients best interest.
• Yet, many (most?) dentists today understand
  themselves to be practicing in the marketplace of
  health care, competing for patients to provide
  for the legitimate expenses of conducting a
  practice caring for patients with the primary
  motivation of earning a significant profit for
  their servicesoperating a business.
• There is difference (a tension) between the
  traditional understanding of the culture of
  profession and the culture of business.

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• A new language has infected the culture of .
  . . health care. It is the language of the
  marketplace, of the tradesman, and of the cost
  accountant. It is a language that depersonalizes
  both patients and health professionals and treats
  health care as just another commodity. It is a
  language that is dangerous.
• Rashi Fein, professor
• Health Economics
• Harvard University

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Socrates in Dialogue with Thrasymachus

• But tell me, your physician in the precise
  sense of whom you were just speaking, is he a
  moneymaker, an earner of fees or a healer of the
  sick? And remember to speak of the physician who
  really is such..."Can we deny then, said I,
  that neither does any physician, insofar as he is
  a physician, seek to enjoin the advantage of the
  physician but that of the patient."PlatoThe
  Republic, 341 B.C.E.

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Distinction Between Social Goods and Consumable
Goods

• An Inquiry Into The Nature and Cause of the
  Wealth of Nations
• Adam Smith
  1776
  
• Argued that there are basic social goods upon
  which the free market for consumable goods is
  dependent, and that these social goods should not
  be considered a part of the market economy.

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Dentistry?

• Is dental care a social good similar in nature to
  police protection, fire protection,, and basic
  health care? public education, public safety?
• Or
• Is dental care a consumable good similar in
  nature to purchasing furniture, electronics,
  vacations, travel, sporting equipment or
  entertainment?

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Categorical Imperative

• Act so that you treat humanity, whether in
  your own person or that of another, always as an
  end and never simply as a means.
• Immanuel KantGerman Philosopher
• 1724-1804

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Patients Means or Ends?

• As a profession, dentists serve the end of the
  well-being of their patients.
• To place ones own interest above the welfare of
  a patient is to treat a patient as means to the
  dentists ends. The patient becomes an object
  to be used by the dentist in achieving personal
  goals. This is reification treating another as
  an object--dehumaning.
• Always treat others as ends in themselves, never
  as a means to ones own ends. Immanuel Kants
  Moral Imperative.
• Clearly we derive financial gain from our lifes
  work, but it is derivative a by-product of us
  fulfilling our promise to our patients as
  professionals that they can always trust us to do
  what is in their best interest.

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Patients Means or Ends

• Dentistry as a business sees the oral health of
  patients, not as ends in themselves, but merely
  means to the dentists personal ends.
• Dentistry as a business serves the end of
  personal profit for the dentist.
• Understanding dentistry primarily as a business
  places dentistry in the marketplace where oral
  health care becomes a commodity produced and sold
  for a profit.
• The business of selling cures undermines the
  classical professional modela model rooted in a
  tradition of caring.

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• Health care is not a commodity, and treating
  as such is deleterious to the ethics of patient
  care. Health is a human good that a good society
  has an obligation to protect from the market
  ethos.
• Edmund Pellegrino, M.D.
• Distinguished BioethicistGeorgetown
  University

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Factors Collapsing Distinction Between Dentistry
as a Profession and Dentistry as a Business

• Power differential going away.(Education of the
  populace, Internet)
• A considerable dimension of dental practice today
  is elective, that is for improved of esthetics,
  and not healthcare in the sense of treating
  disease.
• Increasingly traditional professionals are
  working in corporate/business settings. In the
  U.S. 60 of all physicians work for
  corporationswith a profit motive.
• Business has adopted traditional professional
  standards of putting the client/customer good
  first. The former warning of the marketplace,
  caveat emptor (let the buyer beware) is no
  longer applicable, due to customer guarantees.
• One American bioethicist, William May, has
  suggested that individuals today stand a better
  chance of receiving fair dealing in the
  marketplace of business than they do in the
  offices of the professions.

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A Lingering Question

• Is a visit to the dentist for care
  substantively different than a visit to the
  Porsche dealership to buy a new car, or to the
  grocery store to purchase food, or to the
  department store to purchase a new suit or
  dress?
• If so, how so? Does a distinction, or lack of a
  distinction, result in understanding dentistry
  more as a profession or as a business?

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Charles O. Wilsonand Enlightened Self-Interest

• Charles O. Wilson was the CEO of General Motors
  at the apogee of GMs success in the 1950s.
• While testifying before a Senate Committee he
  made a statement that was subsequently widely
  misquoted as, What is good for General Motors is
  good for the Country.
• In actuality, he said the opposite, What is good
  for the Country is good for General Motors.
• Today, what is good for the oral health of the
  American people is good for the profession of
  Dentistry.
• However, we must be careful not to believe the
  opposite, that what is good for Dentistry is good
  for the American people.

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Defining ProfessionSummarized

• Professions emerged in the Middle Ages in Europe
  with the increasing knowledge, and therefore
  power, of the clergy, attorneys, and physicians.
• Professions profess (promise) to place
  themselves in a fiduciary relationship with their
  constituency. Thus TRUST is the quintessential
  quality of the professional relationship.
• Professions have traditionally been culturally
  distinct from businesses.
• Forces are work in the environment that are
  challenging the validity of the concept of
  profession.
• Yet, their seems to be an inherent difference in
  the transactional relationship between
  dentists/physicians and their patients, and
  automobile salesmen and their customers.