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. 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 imperative 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 fundamental 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 have controlled the discourse on how issues of access are

1236 Journal of Dental Education ■ Volume 70, Number 11 framed and how the oral health care system should patient but also on population health. They are find- be structured. When building moral communities, ing that communities and societies depend on them this is a factor not to be overlooked. to identify and collaboratively address the broader Chambers proposes also that we ought to be determinants of health. concerned first with the process we engage in for Approaching ethical problems from within talking, even before we consider the moral weight of a broader social context, therefore, is becoming the topic of discussion.1 The emphasis at this stage is increasingly necessary.44 Social influences affecting on how different groups come together to talk. The health have been ignored within the field of bioeth- process is meant to facilitate mutual consideration ics.45 For instance, it is in the social dimensions of of proposed alternative meanings for various inten- health care that the question of distributive justice tions and actions that matter. For this to happen, as an allocative principle becomes critical. Indeed, however, all of the stakeholders have to have a place various socioeconomic, professional, and political at the negotiating table, including the voices of those factors influence decision making about what goods historically silenced. In addition, those who have are to be distributed, to whom, and on what basis.46,47 historically controlled the discourse need to acknowl- Moreover, some of the major determinants of health edge this from the outset, and they need to take an are not only about access to care but also factors such active role in creating a more equitable system. This as education, housing, food security, employment, is an essential step for building moral communities social capital, poverty, social exclusion, and life- and a shared and mutually beneficial agenda. Most style.48,49 Accordingly, the way we interact on social, importantly, the process cannot remain oblivious to political, professional, and economic levels can and the principle of nonmaleficence; in fact, the process does affect the health of populations, particularly must also embrace beneficence. the most vulnerable.50 Yet, many applications of bioethical theories do not account for the complexity of human relations and the range of influences on hu- The Disconnect Between man thought and dealings. They seldom account for social constructions of reality, situational constraints, Ethical Theory and Practice evolving societal expectations, and the culture of There is growing discussion using various the organizations within which people work and the principles of social justice in efforts to consider eq- communities in which they live. Rural Alaska’s dental 51 uitable policies and distribution of health services.23-30 access problem is a prime example. Moreover, den- Although discussions about equity, accessibility, and tists’ conceptions of social responsibility challenge justice are beginning to encourage broader thinking the notion that normative theories on social and around the delivery and scope of oral health services, distributive justice are adequate for understanding there are concerns among some educators, policy- how key stakeholders think and reason about issues 52 makers, and practitioners that this is not translating affecting access to care. effectively into permanent and sustainable change in These matters bring to light the professional, everyday dental practice settings.31-34 In relation to political, and economic factors that can and do influ- issues of access and care for vulnerable populations, ence decisions on who deserves what, how much, and there is an observable and acutely felt disconnect who has the power to decide—issues that conven- 53 between theoretical bioethics and the professional, tional theories in ethics do not adequately consider. socioeconomic, and political factors that influence As Weisz points out, theorists, when examining dentistry. For example, patients on social assistance complex situations, “often appear grandly oblivious historically have in many instances felt unwelcome to the social and cultural context in which these occur and have been rejected by some dental and medi- . . . nor do they seem very conscious of the cultural cal practices.35-38 The literature is replete with other specificity of many of the values and procedures they 54 examples affecting equity and access to health care utilize when making ethical judgments.” Without within the context of social justice.5,39-43 In response, opportunity for practical social applications of theo- many health care professionals today are gradually retical ethics, dilemmas and conflicts are more likely beginning to take a greater role in health promotion to remain unresolved, and moral communities can and advocacy, focusing not just on the individual become increasingly difficult to build.

November 2006 ■ Journal of Dental Education 1237 is that unlike issues of access to care due solely Moving from Discourse to socioeconomic factors, those providers who do elect to treat do so in fear despite the risks of medi- to Practice: First, Do No cal harm to themselves.57 There is little evidence to suggest that dental ethics in practice has managed Harm to address these difficulties. One might argue that, While dental professionals and governments first and foremost, dentists have a professional duty continue to debate issues of access or other social to treat as well as the duty to protect patients from determinants of health, there are communities wait- harm that may arise because of a failure to treat.58-60 ing for care, and they have not been invited to the Health care providers, it can be argued, enter their debates to voice concerns and to be heard. Yet, if the professions knowing the risks, just as do firefighters issues are to be addressed effectively and ethically, and police officers, who do not have the liberty to there must be a genuine willingness to understand choose whether they will attend to a particularly bad and ultimately resolve differences through a truthful fire nor the liberty to select the type of criminals they cooperative discourse and toward a consensus moral will deal with. While these are obvious assertions view among all of the different stakeholders. More- for some, as Levine duly points out, “one cannot over, discussions cannot be oblivious to paternalism, argue coherently that there is a duty to be unafraid and most importantly, we cannot ignore harm. . . . one cannot coerce empathy.”61 These are com- The bioethical principle of nonmaleficence is plex situations and do not lend themselves easily to a tenet that is accepted and respected in most com- conventional or normative solutions. munities of professional practice—first, do no harm! When building moral communities, there- It is not about a mere theoretical discussion of harms. fore, we need to determine if socially constructed The widely accepted imperative in dentistry to do no differences that divide stakeholders are avoidable. harm is not only about a negative duty of nonmalefi- Surely, interpretations of inequity and fairness are cence; it is also about a positive duty of beneficence, not solipsistic and without common ground so that positioned within fiduciary obligations vested in the they cannot be carefully assessed within the context health and human service professions generally.55 It of shared principled practices in society generally. seems untenable, therefore, to remain at ease about Yes, there are divisive differences that are inevitable harm while building moral communities. If we allow (biological variations, for example); however, there harm to continue while we are in discussions and are differences that are avoidable and therefore unac- negotiations about social, political, and economic dif- ceptable. According to Whitehead, inadequate access ferences that divide us, then we have in fact ignored to health care and social services is an example of the principles of nonmaleficence and beneficence that what is unnecessary and objectionable.43 Inadequate most learned professionals hold sacrosanct. access to care contributes to further socially disad- There are other examples. A poll of 4,000 vantaging already vulnerable populations. It is within Canadian dentists in the late 1990s found that 16 this context that the tenet of first, do no harm carries percent would not see people with AIDS; 37 percent significant weight. would not see patients with Hepatitis C; 18 percent would not see homosexuals; 35 percent would not see patients who inject drugs; 18 percent would In Closing not see people with STDs; and 10 percent would not see patients who have had blood transfusions.56 Responding to issues affecting oral health dis- Factors associated with refusal to treat were associ- parities and promoting equity for vulnerable popula- ated primarily with lack of ethical responsibility and tions requires an understanding of context, discourse, fears related to cross-infection. As this survey was framing, power, and the communities within which taking place, patients in dire need of dental treatment the problems manifest. When issues of access to care continued to go untreated. To address this problem confront political opposition, especially in highly of nontreatment, we may next want to bring the vari- polarized political environments, we need to be aware ous stakeholders to the negotiating table in search of the frames that are used to sway public opinion for principled as well as practical solutions. Again, and to perhaps introduce and scrutinize appropriate during these discussions, patients will go without counter-frames in an effort to communicate on a treatment. What is different in this case, however, more level playing field. Building moral communi-

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