Leadership

Ethics Fundamentals

David W. Chambers, EdM, MBA, thics is about what is right and 1.1 Legal PhD, FACD good. Only we humans are con - Others decide for you what is legal and Ecerned to live in a world where impose penalties when the rules are Abstract care is taken to bring about the flourish - broken. Dentists do not decide what is Ethics is about studying the right and ing of both ourselves and others, including legal and they accumulate no points the good; morality is about acting as one those we have not met personally. It is for following the law (points are only should. Although there are differences what makes us special. That is why it is subtracted for breaking it). among what is legal, charitable, profes - human nature to strive to live moral lives. Here are some examples of breaking sional, ethical, and moral, these desirable Aside from acting morally because the law. “Upcoding”: submitting an characteristics tend to cluster and are treasured in dentistry. The traditional it is “the right thing to do,” everyone insurance claim for more highly reim - approach to professionalism in dentistry benefits from living in an ethical world. bursed procedures than the ones is based on a theory of biomedical ethics When patients believe that dentists have actually performed; negligent practice advanced 30 years ago. Known as the the patients’ best interests in mind they that results in injury to a patient; or principles approach, general ideals such extend trust to the professional as a failure to report suspected child abuse. as respect for autonomy, nonmaleficence, whole. This increases the likelihood that The “standard of care”—the minimal beneficence, justice, and veracity, are offered as guides. Growth in professional - patients will seek care, makes it possible level of treatment given patients by ism consists in learning to interpret the to provide treatment without having to dentists in a community—is actually a application of these principles as one’s justify every activity, and allows dentists legal construct. It is defined by the jury peers do. Moral behavior is conceived as a to organize professionally to promote in malpractice cases. continuous cycle of sensitivity to situations high standards. Civil disobedience, disregarding the requiring moral response, moral reasoning, It is also known from research in law in order to make a point, is a risky the moral courage to take action when necessary, and integration of habits of corporate America that companies that position for professionals. The high moral behavior into one’s character. This have a reputation for high standards road is to participate in politics, either essay is the first of two papers that provide enjoy greater customer satisfaction, fewer in Political Action Committees or by the backbone for the IDEA Project of the law suits from employees or customers, becoming a political candidate. College—an online, multiformat, interactive more customer and staff loyalty, higher “textbook” of ethics for the profession. profits, and even have employees who 1.2 Charity are physically healthier. Ethics promotes Volunteer and charity work are essentially personal, community, and practice the flip side of legalism. Dentists decide flourishing. what they want to give and there are only points added for participation. 1. Varieties of the Right and the Good No one blames others for not going There is actually a family of behaviors beyond expectations. that address the right and good in related Charity includes mission trips and ways. Ethics is one approach, but so is volunteering at local health fairs. It is behavior that is legal, charitable, profes - unreimbursed and underreimbursed sional, and moral. All are desirable and care (pro bono work), and even general generally cluster together, but there are differences of emphasis.

41 Journal of the American College of Dentists Leadership

good citizenship. America is among the should be returned to the referring gen - on everybody else following the rules. most generous nations in the world. The eral dentist upon completion of specialty Morality is about action, not knowledge American Dental Association estimates care. The code also states that a dentist of the rules. Professors of ethics can the value of dental care for which den - who observes gross or continued faulty cheat on their husbands. Dentists who tists are not fully compensated at about care on the part of a colleague is expected are being sued for violating standards of 5% of all dental care. That is an amount to report that fact. Professional codes professional conduct probably know the roughly equal to the total federal and also contain statements about how state practice act better than the most state dental contributions for Medicaid, professionals should treat patients. For morally upright dentist. prisons, uniformed services, Indian example, a compromising condition in In the end, the moral dentist is Health, and others. the patient’s mouth should be explained the one whose actions bring about As a general rule, professionals are to the patient, even when the dentist healthy patients, harmonious practices, both legal and charity minded. But there was responsible for causing the damag - positive communities, and a stronger are a few dangers in this direction. So- ing situation. profession. They are the ones who called “Robin Hood” practices involve Codes of professional conduct were would be most missed, not because of illegal redistributions of the wealth. A historically known as Codes of Profes- what they always said, but because dentist may post-date an insurance claim sional Etiquette because they govern the of what they always did. to make it easier for the patient to get relationships among practitioners. They Moral practitioners behave legally, reimbursement for an otherwise uncov - are developed by professionals and are charitably toward all, professionally, ered procedure. This is illegal, but very for their use. Patients and public entities and act from a firm theoretical ground - charitable. (It also contributes to the are not invited to participate in the ing in an ethical framework. But it is dentist’s financial and reputational bot - creation or updating of professional their life pattern of moral behaviors that tom line, makes the dentist an arbiter of codes, nor are they expected to comment sets them apart as being the ones we worthy causes, and is all accomplished on them. all want more of. with someone else’s money.) 1.4 Ethics 2. Ethical Analysis 1.3 Professionalism In its pure form, ethics is the study of Obviously the task of building a moral Groups from the United States Senate to right and wrong, good and bad. This is community in dentistry is not simple or the local plumbers’ union make rules an academic pursuit, largely confined easy—otherwise it would have been done governing the behavior of their members. to departments of philosophy in univer - by now. Sometimes there is disagree - These rules guide how members are sities. Bioethics or the ethics of dentistry ment over whether a particular action expected to behave toward each other would be properly termed “applied leads to a necessary good; sometimes and toward others. Such “codes of con - ethics.” It is about reflecting on princi - there is disagreement over what to do duct” are often written down, but there ples and learning to give good reasons when something rotten is found. Ethics are always numerous informal rules for behavior. On this view, moral is an art, and a group performing art that can only be learned on the job. philosophers and bioethicists work to at that. Informal rules have the advantage of define what is ethical and practitioners The field that covers dental ethics is making it easy to spot someone who seek to clarity how these principles called bioethics or professional ethics. does not belong. Professional codes are apply in various situations. As a discipline it is barely 30 years old. usually aspirational, meaning that they The goal of bioethics is to offer guidance define a generalized ideal rather than 1.5 Moral Behavior to healthcare practitioners and policy hard-and-fast criterion that cause Moral behavior is patterns of action makers about how to act. The center someone to be sanctioned. that are consistent with the best theories of the approach is something called the For example, the ADA Code of of ethics. It is about individuals and practical ethics syllogism. With roots Professional Conduct (not the ADA particulars. We might ask ourselves: If all the way back to Aristotle, the practi - Principles of Ethics ) states that patients we were on trial, accused of being ethi - cal ethics syllogism works something who have been referred to a specialist cal, would there be enough evidence to like this: get a conviction? Ethics defines the Principle: All ethical healthcare theoretical context; moral behavior is professionals strive to benefit their the evidence. When con artists, cops, patients. 42 and politicians go bad, they are counting

2011 Volume 78, Number 3 Leadership

Analysis: In the current situation, are examples. These cases can be tricky, action A would provide a net benefit varying from state to state in the legal to the patient. sense. It is almost never the case, cer - tainly, that patient’s lack of autonomy Moral behavior: If Doctor D is an transfers any authority to the practitioner. ethical healthcare professional, he or Neither should the principle of she will do A in this situation. patient autonomy be misunderstood as Notice in this form of ethical reason - meaning that dentists are ethically ing, there is a major premise or principle bound to do whatever patients request. that encompasses practitioners, patients, Especially, when dentists can see that a and situations generally. But that is patient is requesting something that, in insufficient to guide action in all cases. the dentist’s opinion would harm them, Only we humans are Particular situations are ambiguous and the dentist acts morally by denying the difficult to interpret, there are complicat - request. (That does not extend, however, concerned to live in a world ing and even conflicting factors; there to the dentist being allowed to decide where care is taken to bring may be exceptions. Consequently, there what should be done instead.) The prin - is a second step where the principle is ciple of autonomy applies to respect for about the flourishing of both analyzed and interpreted in the specific the dentist, and every member of the ourselves and others. context. So ethical training must be dental team, just as it does to patients more than learning how to spell non - and to patients’ families. maleficence; it must also include building skill in interpreting complex situations 2.1.2 Nonmaleficence means avoiding in the light of general principles. actions that cause unnecessary harm. It is a double negative principle, and 2.1 Ethical Principles thus not always the same as beneficence. The major premises in ethical analysis The only way to guarantee no harm is to have been developed by philosophers. perform no care: there is always risk in In bioethics, there are four generally any treatment. Practically, the principle accepted principles (autonomy, non - of nonmaleficence is about negligence; maleficence, beneficence, and justice); it means abstaining from exposing there is one additional one (veracity) patients to unreasonable and unforseen that dentistry has embraced. risks. Framed in positive terms, non - maleficence involves becoming highly 2.1.1 Autonomy means self-determina - competent, knowing the science behind tion. Literally, the Greek origin of the what is being done, being in tune with word is “to give oneself the law.” Legally, the standards used by one’s colleagues, patients have complete say about what and engaging the patient in understand - can be done to their bodies. They must ing and choosing the level of risk they give permission, called informed con - are comfortable with. sent, for any act of the dentist or office staff. Sometimes this principle is referred 2.1.3 Beneficence means providing a to as respect, and that is a useful per - benefit or helping others. This is a spective because it reminds us that we positive obligation: others must be net decide on behalf of others at our own better off for their contact with dentists peril and in doing so we diminish others. than they would be otherwise. Excellent Not everyone is entitled to full reconstructive work would probably autonomy. Children, the mentally incompetent, and others for whom the court has identified another as the decision maker (e.g., convicted felons) 43 Journal of the American College of Dentists Leadership

not qualify as beneficence if the patient were overcharged relative to receiving 2.1.5 Veracity means not misleading or the same quality of care for a lower fee allowing another to be misinformed or with greater convenience. There is or misled. This is just a little larger and an implied contract between society and more flexible than telling the truth. professionals: the profession is granted If a dentist lists credentials that create a limited degree of autonomy and self- an impression in the patients’ mind that governance in exchange for benefiting specialty training has been completed or the public. (It is actually assumed that that a procedure has a high success rate professional self-governance will auto - despite only saying “clinically proven,” matically magnify the level of benefit.) the patient is justified in making a choice Ethics is an art, and Beneficence can be confused with they would not otherwise make if they paternalism. Both principles intend to had the full story. That is a violation a group performing art provide benefit for patients. In benefi - of the principle of veracity. A good test at that. cence, the patient participates in and of the principle is to ask: Does the ultimately determines what benefits they practitioner stand to gain personally most value. In paternalism, the practi - by withholding any information that tioner makes that decision on behalf could reasonably be made available? of the patient. Naturally, the maximal The first four of these principles net good by means of the principle of are enshrined in the bioethics cannon beneficence and by the principle of and were first introduced by Tom paternalism are usually the same action. Beauchamp and James Childress in their But that is not always the case. And when 1977 book Principles of Biomedical there is a conflict between these two Ethics . This is sometimes called the principles, the practitioner must choose. “Georgetown Manta” for the fact that Beauchamp and Childress worked at 2.1.4 Justice means that the benefits and the Kenney Institute for Ethics at the the burdens in society are fairly distrib - University of Georgetown. Other princi - uted. Ideally, it is unjust to charge one ples such as fidelity and privacy have patient more for a procedure than is been identified. Dentists should be charged to a different patient for the aware that this is primarily a healthcare same procedure or to make it more diffi - ethics perspective. Moral philosophers cult for one class of patients to be treated in universities generally do not work than another. (Practically, this is done all with this framework. the time throughout American society.) There are so many ways for classifying 2.2 Analysis of Principles or categorizing each case, that every The excitement in ethics does not come effort to be fair leaves some room for in debates over principles. There is near individuals who as dissatisfied with the universal agreement that justifiable outcome to voice a complaint. That is criticism of gross or continuous faulty why the justice system has so many work by colleagues is “right” and that lawyers. It remains, however, an aspira - false and misleading advertising is tional principle to treat everyone as “wrong.” Issues arise in the application fairly as possible and especially not to of the principles. There are some practi - treat groupings of individuals solely for tioners who claim never to have seen the sake of increasing one’s own benefit. cases of colleagues’ work that was so faulty as to require criticism. There really are shades of interpretation in what is misleading in advertising. The principles 44 are abstract; their application is concrete,

2011 Volume 78, Number 3 Leadership but open to interpretation. in which care is given, there are nuances of peers. Sometimes this approach will And to make matters worse, there of professional relationships, there are also be used to assess specific moral can be conflicts among the principles procedural options. No dental student acts of one’s colleagues. themselves. Patient autonomy fights could be expected to master the interpre - A fuller answer is provided by the with nonmaleficence. Beneficence in tation of ethics while still a student. moral psychologist James Rest. Rest being able to help one patient fights Certainly no non-dentist could under - proposed a Four Component Model of with justice in not being able to help all stand it. Obviously, a few practitioners moral development. This goes beyond patients. Where two (or more) principles do not get it either. reasoning on specific isolated ethical can be read as framing a particular The standard in teaching ethics in challenges. His model has been tested in situation but favor contradictory actions, dental schools is the case method or many disciplines, including dentistry, we call this a moral dilemma. The term ethical dilemmas. Students rub their ten - and there are short, paper-and-pencil comes from the Greek word lemma tative interpretations up against those of tests for measuring one’s profile on the meaning a stock, halfway proof of part their colleagues and some experienced four components of the model. Although of a theorem that can be used in many veterans. The overwhelming majority there are four parts to the model, it has settings as a shortcut in parts of various of ethics publications on ethics in the been demonstrated that one can begin proofs. Hence two stock part proofs or dental literature are cases, with analyses. building moral strength at any point, a di-lemma. This approach to ethics training goes and double back part way through the Ethics education is generally under - back to Aristotle in the fourth century path as needed. Research shows that stood as training in how to apply BC. Now called “virtue ethics,” the model the components are trainable and that principles. (Many philosophers would is designed to qualify one for member - moral growth is possible well into the take exception to this definition as ship in the community of one’s peers. thirties and longer. incomplete.) All such education takes Virtue ethics is now the standard taught place in actual communities where in America’s business schools. Aristotle 3.1 Moral Sensitivity cases are discussed and analyzed from expressly limited ethical reasoning to The Cambridge moral philosopher a common perspective, thus teaching free-born males of mature age and Simon Blackburn notes that very few how to interpret ethical situations and excluded slaves and women as being people are actually bad by nature, but properly apply the principles. That is incapable of ethical reasoning. Physicians many are ethically blind. The first what happens in our early family train - and lawyers, as well as other professions component in moral development is to ing and in kindergarten where author exclude the lay public, politicians, or cultivate the habit of seeing the moral Robert Fulghum said he learned every - insurance companies from learning or dimension in situations around us. Few thing important in life. It takes place contributing to the conversation about dentists, for example, agree that where in a midrash, a kibbutz, seminary, the professional ethics to this day. All profes - they choose to locate their practice is an military academies, law school, and sions struggle with the proper boundaries ethical decision. This decision does, dentistry. Even where there is overlap between professionalism and ethics. however, have profound and persistent in principles, the traditions of interpreta - influence on who they treat and what tion are unique to the community 3. Becoming a Moral Person kind of care is provided. Many profes - where interpretation is learned. So far, we have a workable grip on ethics, sionals assume that the cost of new A novitiate earns recognition as a especially on ethical reasoning and talk - regulations and patient safety procedures member of the community by mastering ing about ethics. But we need to push on should automatically be passed through the art of correct interpretation of ethical to the moral behavior of practitioners. 100% to patients without stopping to ask principles within the group. An impor - What does it mean for dentist to exhibit whether this is an issue involving justice tant part of becoming a dentist is learning a consistent pattern of actions that pro - or whether regulators are making laws how to see things as dentists do. The mote the right and the good in practice? meaning of gross and continuous faulty An abbreviated answer is that profes - care has to be learned. There are shades sionals who become aware of possible of fault, there are ranges of circumstances doubts about whether what they are doing is ethical can engage in reflection grounded in ethical principles and the interpretative habits of their community 45 Journal of the American College of Dentists Leadership

because they think consumers are taking working with principles. Rest refers to advantage of providers. Is informed these three levels of moral reasoning consent a legal matter or an ethical one? as preconventional, conventional, and Are there ethical overtones to insurance, postconventional. These are categories Medicaid, and emergency call? of approaches to reasoning, not right - Rest’s point on moral sensitivity is ness or goodness. A dentist could be simply that all opportunity for ethical perfectly ethical following the trend of growth is blocked in areas where the professional colleagues or end in a really opportunity is not first recognized. indefensible position by concocting an elaborate theory from new cloth. 3.2 Moral Reasoning The principles are The second component is the familiar 3.3 Moral Courage skill of sorting through what is at stake Just as there are individuals who are abstract; their application in an ethical problem, locating the rele - hypertensive to ethical abuse in the is concrete, but open vant principles, finding whose interests world but cannot figure it out, there are are at stake, tracing out consequences, those who have worked through sound to interpretation. narrowing down the alternatives, and understanding of right and wrong and deciding which is the preferred course of remain paralyzed when required to action. This is the abstract part of ethics take action. Moral courage refers to the and stops just short of actually doing interpersonal communication skills and anything. Sometimes we react quickly, political and personal connections as framing the problem as another exam - well as the willingness to take personal ple of situations we have seen before. risks to engage in moral behavior. This, Occasionally we wrestle with novel and of course has be understood as direct complex matters that challenge us to moral action in support of strong moral recognize something new. But in all, we reasoning. It does not count to engage in are trying to solve an intellectual problem. character assassination or bellyaching. This is the part of the Rest model that has been most fully developed. 3.4 Moral Integrity He built his approach on earlier work Some people are known as being espe - that showed that as we grow in age, we cially upstanding. They were troubled naturally change the overall approach by an issue, they worked it through, and we take to solving the intellectual then took action. Those who do this aspects of complex ethical problems. predictably, who make a general habit Young children tend to equate the right of it, who can be counted on to work for and the good with what those in author - a world that is right and good exhibit ity approve or punish. Older children moral integrity. and teens more typically opt for an analysis in terms of the standards of those in their community. In maturity, and only for some, does ethical reason - ing take on the character of systematic

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2011 Volume 78, Number 3