Dentistry as a Business in Tension with Dentistry as a Profession.

Dentistry as a Business in Tension with Dentistry as a

Profession

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.

• Norms-what the culture understands as normal; that which should occur naturally; the culture’s 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.

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

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

“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

“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

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

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 patient’s 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 services—operating a business.

• There is difference (a tension) between the traditional understanding of the culture of profession and the culture of business.

“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

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.

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.”

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?

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

Patients: Means or Ends?

• As a profession, dentists serve the end of the well-being of their patients.

• To place one’s own interest above the welfare of a patient is to treat a patient as means to the dentist’s 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 one’s own ends.” Immanuel Kant’s Moral Imperative.

• Clearly we derive financial gain from our life’s 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.

Patients: Means or Ends

• Dentistry as a business sees the oral health of patients, not as ends in themselves, but merely means to the dentist’s 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 model—a model rooted in a tradition of caring.

“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

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 corporations—with 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.

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?

Charles O. Wilsonand

Enlightened Self-Interest

• Charles O. Wilson was the CEO of General Motors at the apogee of GM’s 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.

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.