The Ethics of Access and Trust — Do We Have a Greater Role to Play?

This column is a collaboration between AGD and the American College of Dentists. 

Adaptability, resilience, fortitude, courage and leadership are all terms that come to mind when considering the myriad challenges dentists around the country and globally have faced during the last 2 1/2 years. The COVID-19 pandemic surely had negative effects, including the loss of loved ones, friends, colleagues and even patients. Interruption of comprehensive care for patients, many of whom were the most in need, loss of clinical revenue as well as high turnover of oral healthcare teams and workforce issues continue to abound. 

While in no way intended as a slight to the abundant tragedies and losses, this time has also served as a catalyst for change, creativity and opportunity — a positive disruption of sorts. Disruption is thought to be a break in the status quo or some interruption from the normal way of doing things. In several genres, from corporate to legal to nursing, positive disruption, also coined disruptive innovation, communicates an innovation that provides a simpler, more convenient, more accessible and more affordable alternative to traditionally accepted ways of operating.^1-3 In clinical practice, we’ve seen an expansion of scope of practice (vaccine administration and dissemination), technological advances (more broad acceptance of teledentistry), and even improvements in access to care (expansion and/or inclusion of adult dental comprehensive care to state Medicaid programs). COVID-19 also moved understanding and discussion of health disparities and inequities from isolated silos of academic query to front-page news, trending social media topics and dinner table conversation. 

With so much public discussion of health disparities and inequities, the profession of dentistry begs for a thorough and complete self-examination. What sets dentistry apart as a profession? Dentistry holds a special position of trust within society. As a result, society affords the profession certain privileges that are not available to members of the public-at-large.⁴ The concept of societal trust is inextricably linked to dentistry’s professional status and the social contract embedded within it. Physician colleagues understand that “society granted physicians status, respect, autonomy in practice, the privilege of self-regulation, and financial rewards on the expectation that physicians would be competent, altruistic, moral and would address the healthcare needs of individual patients and society.”⁵ Does dentistry, both individually and as a collective profession, share this understanding of the social contract? Anecdotally, every practicing dentist has rounded the office corner, heading into the operatory to meet a new patient, and heard the endearing words: “I hate dentists.” 

While often dismissed and easily regarded as simply an awkward introductory exchange, an ethics and professionalism lens would cause one to stop and consider just what that patient is expressing. The greater issue at hand is that one action, or nonaction, by an individual dentist has the potential to forever influence the patient’s impression of the entire profession. So, if the social contract links patient trust to meeting the needs of both individuals and society, the logical question becomes: Is dentistry upholding its professional obligations to the societal issue of access to care? 

Participating in Mission of Mercy, Give Kids A Smile, Dental Lifeline Network and similar charitable programs; creating in-house discounted service plans; and even offering occasional or regularly intervaled altruistically motivated free care are all laudable and worthwhile pursuits. These programs certainly meet a need for those who may not otherwise receive much needed care. Perhaps the dental ethical mandate calls for more? The American Dental Association’s Principles of Ethics & Code of Professional Conduct includes beneficence, or to do good. “The dentist has a duty to promote the patient’s welfare.”⁴ It further stipulates that “since dentists have an obligation to use their skills, knowledge and experience for the improvement of the dental health of the public and are encouraged to be leaders in their community, dentists in such service shall conduct themselves in such a manner as to maintain or elevate the esteem of the profession.”⁴ This explanation of duty is lodged under the notion of community service. While community service is undoubtedly a commendable pursuit, why limit “improvement of the dental health of the public” to only community service? 

Cost and availability are significant barriers to accessing dental care among low-income Americans. For example, state Medicaid programs enable access to care by removing cost as a barrier. For patients to access care, dental professionals must be available in the community, enrolled in Medicaid programs, and willing to provide care to Medicaid recipients on as equitable a basis as private pay patients.⁶ Of course, there are myriad significant barriers and issues, many administrative and due to low reimbursement rates, influencing provider decision and autonomy to enroll as a Medicaid provider. However, the ethical and professionalism lens again begs the question: Why is there such low dentist acceptance for Medicaid, let alone advocacy for improved systems and reimbursement rates? Some studies have shown provider stigma, or peer pressure from fellow dentists toward those who participate in Medicaid and potential reactions from non-Medicaid patients toward patients in dental offices utilizing public insurance programs as their method of payment.^7-9 

Even more recently, as national debates emerged over possible inclusion of dental care in Medicare, it is important to ponder whether the position of organized dentistry was formulated through an ethical decision-making model or simply by considering office profits? Dentists, particularly those with responsibilities as business owners or partners, having responsibility not only for themselves but also the livelihood of others, have and will always face competing ethical priorities or principles. Profit, revenue and upward mobility are not dirty words or to be shunned. However, can profit exist alongside ethical and professional conduct? One would think some question that dentistry must consistently ask itself is whether one or the other is driving the proverbial train. 

Some providers have accepted public insurance programs at one time or another and withdrawn. How did they come to that decision? Frustration, fear, bias or exasperation with a seemingly broken system may be possibilities. Late patients, inability to meet co-payment thresholds, double booking practices — while all likely experiences, what should an ethical response be? Take the late patient — why are they late? What other priorities might they have? What are the barriers they must overcome to obtain care? Low-income patients, already amongst the nation’s most vulnerable, are often facing competing priorities around hourly wage earning, ability to take time off, transportation hurdles, or even a lived reality of making the woeful decision between paying one bill versus another. These barriers are known as the social determinants of health — those conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life.”¹⁰ 

In a society and country where disruptive innovation has produced great advances across genres and industries, could the dental profession become a positive disruptor surrounding the issue of access and trust? While there is most certainly no singular answer or best practice, the ethical and professional imperative is to — quite simply — ask the question. How will each of us, from varying positions, angles, practice philosophies, special interests or perspectives, answer? The cultivation of greater public trust and easing the burden of access may just be in the journey of query and not simply the destination alone. 

Carlos Stringer Smith, DDS, MDiv, FACD, is an associate professor and director of ethics curriculum and director of diversity, equity and inclusion at Virginia Commonwealth University School of Dentistry, Richmond, Virginia. An actively practicing general dentist, he is president-elect of the American Society of Dental Ethics. To comment on this article, email impact@agd.org. 

References 
1. Thompson, C.J. “Disruptive Innovation: The Rise of Distance Education,” Clinical Nurse Specialist, vol. 30, no. 4, 2016, pp. 238-241. 
2. Thompson, C.J. “Distance Educators: Forgotten Faculty or Positive Disruptors?” Clinical Nurse Specialist, vol. 31, no. 1, 2017, pp. 52-56. 
3. Saeed, S., et al. “COVID-19: Finding Silver Linings for Dental Education.” Journal of Dental Education, vol. 84, no. 8, 2020. 
4. Principles of Ethics & Code of Professional Conduct. American Dental Association, November 2020, ada.org/-/media/project/ada-organization/ada/ada-org/files/about/ada_ code_of_ethics.pdf. Accessed 28 June 2022. 
5. Cruess, S.R., and R.L. Cruess. “Professionalism and Medicine’s Social Contract with Society.” AMA Journal of Ethics, vol. 6, no. 4, 2004, pp. 185-188. 
6. Metcalf, S.S., et al. “The Impact of Medicaid Expansion on Oral Health Equity for Older Adults: A Systems Perspective.” Journal of the California Dental Association, vol. 43, no. 7, 2015, p. 369. 
7. Logan, H.L., et al. “Barriers to Medicaid Participation Among Florida Dentists.” Journal of Health Care for the Poor and Underserved, vol. 26, no. 1, 2015, p. 154. 
8. Behar-Horenstein, L.S., and C.W. Garvan “Relationships Among the Knowledge, Efficacy, and Practices Instrument, Color-Blind Racial Attitudes Scale, Deamonte Driver Survey, and Defining Issues Test 2.” Journal of Dental Education, vol. 80, no. 3, 2016, pp. 355-364. 
9. Behar-Horenstein, L.S., and X. Feng. “Dental Student, Resident, and Faculty Attitudes Toward Treating Medicaid Patients.” Journal of Dental Education, vol. 81, no. 11, 2017, pp. 1291-1300. 
10. “What Are Social Determinants of Health?” World Health Organization, who.int/health-topics/social-determinants-of-health#tab=tab_1/. Accessed 11 July 2022