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Building Moral Communities? First, Do No Harm Shafik Dharamsi, Ph.D

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Building Moral Communities? First, Do No Harm Shafik Dharamsi, Ph.D Building Moral Communities? First, Do No Harm Shafik Dharamsi, Ph.D. Abstract: As concern for the oral health of vulnerable populations grows, dentistry continues to seek effective ways to respond. In August 2005, Dr. Donald Patthoff and Dr. Frank Catalanotto convened a national workshop at the American Dental Associa- tion headquarters on the ethics of access to oral health care. A series of papers were produced for the workshop and subsequently revised for publication. This one responds to the paper by Dr. David Chambers on moral communities and the discursive impera- tive for building community and consensus around issues affecting equitable access to oral health care. I explore three interrelated issues that ought to be considered when endeavoring to build moral communities: 1) the problem of power relations—a funda- mental constituent within discourse that can impede constructive efforts; 2) the discursive disconnect between theoretical ethics and social constructs affecting dentistry; and 3) the bioethical principle of nonmaleficence as a priority in the desire for building moral communities. In essence, this article responds also to the call from ethicists who see a significant need for substantive interdisciplinary contributions to inform how people at different social levels react in ethically problematic situations in its broad social context. Dr. Dharamsi is Assistant Professor, Global Oral Health and Community Dentistry, Division of Preventive and Community Den- tistry, and Associate Director of the Center for International Health at the University of British Columbia. Direct correspondence and requests for reprints to him at the University of British Columbia, Faculty of Dentistry, 2199 Wesbrook Mall, Vancouver, BC, Canada V6T 1Z3; 604-822-7288 phone; 604-822-6989 fax; [email protected]. Key words: access, ethics, vulnerable populations, discourse, framing, power, social constructs, nonmaleficence n August 2005 various stakeholders came to- moral communities: 1) challenges posed by power gether at the American Dental Association (ADA) relations embedded in discursive and framing prac- Iheadquarters to discuss the ethics of access to tices—I argue also that understanding discourse from oral health care in relation to professional and social the vantage of postmodern social theory is crucially responsibility, social justice, codes of ethics, and how important for addressing ethical quandaries affecting to educate better the next generation of health provid- disparities in health; 2) the disconnect between ethi- ers to address related issues. A series of papers were cal theories and social constructs affecting dentistry; generated and subsequently revised for publication. and 3) the duty to consider the bioethical principles This one responds to David Chambers’s robust thesis of nonmaleficence and beneficence as a fundamental on building moral communities and the imperative constituent in building moral communities. of open and honest communication for developing community and consensus on issues that affect them.1 Chambers provides us with a much needed founda- Dentistry and Vulnerable tion for dialogue and community building. Moral communities are those that share ethical Populations concerns, value pluralism, have a keen sense of social As concern for the health of vulnerable popu- responsibility, and strive for a broader moral identi- lations grows, dentistry continues to seek effective fication and sense of duty beyond social, economic, ways to respond. Vulnerable populations, acknowl- cultural, or political differences. I accept Chambers’s edges the ADA, “are often limited by physical dis- thesis that good communities need to build discursive abilities, illness, poverty, and other socioeconomic relationships if they are to reach consensus around conditions that impede their access to needed care.”2 issues that have divided them generally. He argues In their detailed examination of the inequities in well that to build moral communities requires a keen health and health care experiences among vulner- awareness of the impact of coercion and misrepre- able populations, Shi and Stevens provide a broad sentation, the import of rhetoric on building ethical definition of vulnerability to include various social, communities, and the value of persuasion if done economic, political, environmental, or biological well and done honestly. conditions that prevent people from protecting their I offer for consideration three interrelated own needs and interests.3 Vulnerable populations tend factors that can have a profound effect on building to experience worse health outcomes, they face bar- November 2006 ■ Journal of Dental Education 1235 riers to care, they have higher rates of morbidity and wants to be labeled as “anti-life,” hence the emer- mortality than the general population, and they have gence of “pro-choice,” a counter-frame. The same little or no control over the conditions that contribute can be applied to “dental auxiliaries” versus “allied to their situation. Most stakeholders agree that these dental professionals” or “radical” versus “innova- are significant problems and must be addressed. But tive.” In essence, we do not speak a language more not everyone agrees on how to address them. so than it speaks us. Those who study discourses and There is ongoing debate among health profes- framing focus on vocabularies of speech or writing sionals and governments around the locus of social and their implications in social relationships. They responsibility for treating vulnerable populations.4-6 examine how speech embodies the beliefs, values, Contentious matters have resulted in class action and categories that constitute a way of looking at the lawsuits by some patients against the state7 and world and experiencing the world and how, within the more recently a suit by the ADA against the Alas- communicative context, particular ideas are reified. kan Native Tribal Health Consortium.8 While the They study how discourses and frames reflect prevail- debates continue, those who historically were only ing ideologies, values, beliefs, and social practices sporadically able to access care find themselves fur- and how they inevitably permit certain claims while ther marginalized.9 Conversely, of the dentists who marginalizing others. continue to provide care to the disadvantaged, many Apartheid provides an obvious and pointed become morally and emotionally exhausted and/or example. Those who observe its tenets have come financially challenged.10,11 It is within these contexts to view their practices as part of common sense. that Chambers’s contribution on building moral com- They hold a dominant place in society and have the munities is most helpful. power to frame the issues at stake. They interpret as legitimate their conceptions of how society works or should work, and they talk about and act in that Discourse, Framing, and society in determined ways, embedding their ideas in various social, political, legal, and economic institu- Power tions and accepting unreflectively that who they are In his thesis on moral communities, however, and what they do are natural and true. It is a socially 22 Chambers avoids the power dimension of discourse.12 constructed reality. Their discourses and ways of It is a concept that emerges in the scholarship of framing issues and related practices become hege- several notable educators and social scientists.13-19 monic and harmful as they promote unreasonable but Discourses play a significant role in articulating, pre- dominant ideas and activities as normal. serving, and enforcing relations of power in society. Discourses and frames are not casual or Discourses affect all social institutions and are ad- transient; they are determined and prescribed. The opted and adapted in ways to allow us to make sense language is powerful and expressed through strong of our actions and reasoning and to actively shape and confident voices belonging to those who hold and order our relationship to the social world. It is a privileged positions in society and who have devel- concept that is reflected also in the theory of fram- oped a legitimacy to speak and to be heard. Not all ing: the use of language to fit a particular worldview members of the community are given or can assume and serve to structure how we define, interpret, and this privilege or have the opportunity to respond; it understand reality.20 Framing, explains Entman, “is to depends on the standing one has within a community. select some aspects of a perceived reality and make Those who can and do control the discourse have a them more salient in a communicating text, in such protected place at the table and have the power to a way as to promote a particular problem definition, define the position of others. Chambers suggests, causal interpretation, moral evaluation, and/or treat- however, that the many differences in common sense ment recommendation.”21 Take the terms “pro-life” values can be negotiated in the process of building 1 and “pro-choice,” for instance. The implications moral communities. Nevertheless, the direct and embedded in them are quite powerful. Those who indirect influence of framing can have a significant embrace “pro-life” take a determined moral position impact on the negotiation and its outcome. In den- against abortion. The term “pro-life” implies that tistry, for instance, mostly professionals have tended its opponents are “anti-life” or “pro-death.” No one to occupy seats at the decision table, and they
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