DENTAL ETHICS

 
Jos VM Welie
The Future of Dental Ethics. Reflections of a Past Secretary.

After a decade of administrative engagement in IDEALS – one-and-a-half years in preparatory activities and eight-and-a-half more years on the Board as Secretary– it seems a fitting moment to look backward as well as forward.

My own entry into the field of dental ethics almost 20 years ago was unplanned and unexpected. Other than as a patient, I had no background in dentistry. I had attained degrees in medicine, philosophy and law. But my only connection to the field of dental ethics was my marriage to a Texan dental-hygienist who was one of the early pioneers in dental ethics. Having arrived at the Radboud University (Nijmegen, The Netherlands) in the newly established Department of Ethics, Philosophy and History of Medicine, my boss told me to take on the lectures in the school of dentistry, for I, unlike any of the other members in the department, at least had an indirect link to dentistry. When in 1997 I accepted a position at the Creighton University Center for Health Policy and Ethics (Omaha, USA), something similar happened. Because nobody else at the Center had a dental background, and I was the "new kid on the block," I was sent to the School of Dentistry to assume the dental ethics courses.

I should emphasize that both in Nijmegen and in Omaha, my work with colleagues in dentistry has always been very satisfying. My lack of formal training in dentistry notwithstanding, the faculty members of both dental schools have always been very accepting of my activities and indeed appreciative (of course the students were more cynical about a non-dentist instructor). I also came to enjoy my work in dental ethics tremendously. Unlike my primary area of expertise, that is, medical ethics, the field of dental ethics is still contained. It is relatively small in terms of the individuals who do exciting work in this area – and so one can get to know just about everybody and develop a very close and collegial network. And it is relatively small in terms of the agenda, as can be expected of any discipline that is still young and not yet hyperspecialized. So one can attain and maintain a solid overview of the whole field and most of the new developments.

I tend to like constructing things, and there is a whole lot yet to be built-up in dental ethics. Back in the late 1990s, there was no international organization in dental ethics. The US-based Professional Ethics in Dentistry Network (currently known as the American Society of Dental Ethics, which recently merged into the American College of Dentists) was in place and had already accomplished some remarkable advances, growing the field of dental ethics literally out of nothing. But its reach did not really exceed North America. By happenstance I also discovered that back in the Old World, three international (though largely European) conferences had already taken place, originally limited to the field of dental law but subsequently expanded to dental law and ethics. So I tracked down the founder of these conferences, who turned out to be a dentist-lawyer from Belgium, Yvo Vermylen. It was in his backyard that the plan for a new international organization was hatched. And in December of 2000, with the help of a very dedicated international team of co-conspirators, IDEALS was founded.

The founding board of IDEALS had among its members two dentist-ethicists: Gunilla Nordenram from Sweden and Sefik Gorkey from Turkey. The other two ethicists were not dentists by training and profession: Sytse Strijbos and myself. (There were also two dental lawyers on the board who were not trained as dentists, but I shall limit my reflections to the field of dental ethics). Sytse Strijbos (from The Netherlands) had just written the first textbook in Dutch on dental ethics. Strijbos left the Board (and the field of dental ethics) some years later. Now it is my turn. I venture to guess that he would agree with me that this development is actually fitting and indeed a sign of progress. For the field of dental ethics should be squarely in the hands of dental professionals.

The practice of dentistry and oral health care is itself morally laden. That is to say, one cannot define dentistry without referring to values. All of the most basic concepts in oral health care are ethical concepts such as health, disease, disability, normal, pathological, well-being, relief of suffering, optimal functioning, interests, etc. Hence, only those who have been trained in the science of dentistry and have practiced oral health care can attain a full understanding of dental ethics.

It may take – and indeed, I would argue that it will take – additional study for a dentist to become a leading dental ethicist on par with the leading ethicists in the field of medicine or nursing. Alternatively, the profession can encourage students who have a strong academic background in ethics to embark on the study and subsequent practice of dentistry. But ultimately, the field of dental ethics cannot be brought to fruition by experts like Bruce Weinstein and David Ozar (in the USA), or Sytse Strijbos and Bert Gordijn (in The Netherlands). They may have authored the first generation of modern dental ethics textbooks, but all are philosophers by profession and lack the necessary background in dental science and practice to really move the discipline to the next level. Thus it is a genuine sign of progress that all individuals on the current IDEALS Board who work in the field of dental ethics are dentists as well.

Nearing its 9^th birthday, IDEALS can boast a number of important other successes. The society enjoys a core group of very dedicated members, willing to serve on the board and other committees, assisting in projects, and writing for the IDEALS Bulletin. Financially, IDEALS is quite stable – in large part due to the fund raising efforts of our former president, Dick Speers – with a cash reserve that can now be used to cover up-front expenses of congresses. We have a robust website, which needs to be expanded with services and information for the IDEALS members, but which has already made life much easier for Board members charged with administering the Society (including electronic membership sign-up forms, database and committee maintenance, book keeping, abstract submission and review, chat room, document storage, voting, etc). One of the principle reasons to establish IDEALS was to assure that the series of international congresses, initiated back in 1992 by Yvo Vermylen but still homeless at the time, would continue under the auspices of IDEALS. Indeed, it has. After four European meetings (Louvain 1992; Copenhagen 1995; London 1998; and Amsterdam 2001), IDEALS was able to bring the 5^th congress to North America (Omaha 2003), with subsequent congresses in Italy (Florence 2005) and Canada (Toronto 2007). Another excellent conference, scheduled for 2010, is now being prepared in association with several Finnish co-organizers. In addition, one regional IDEALS meeting took place in Australia (Brisbane 2006). Another international success is the 2007 adoption by the FDI World Dental Federation of the "Guidelines for Dentists Against Torture." The impetus for the development of these guidelines came from our Immediate Past President Dick Speers and IDEALS played a major role in the drafting of the text.

As the same time, I am concerned about the future of the discipline of dental ethics. Although there exist only two associations specifically dedicated to the field of dental ethics (ACD/ASDE and IDEALS) and although IDEALS combines ethics and law and hence should be even bigger than if it had focused on dental ethics alone, both ASDE and IDEALS still have small and fledgling memberships (each fewer than 100 members, some of whom are members of both associations). There are more than 70 dental schools in the US and Canada alone, all of which have formal dental ethics education incorporated into their curricula. Add to this the number of dental schools in other countries around the world that nowadays offer courses or course components in dental ethics, and the number jumps to several hundred, more likely several thousand. If the course directors, lecturers, and small group session leaders charged with these course offerings were to all be members of IDEALS, it would be a robust organization that could really move the field forward. Add to this the individuals in all of the national dental associations who are currently chairing ethics committees, as well as the individuals serving on peer review committees and working groups on professionalism, health care reform, ethics of dental research and a variety of ethical other topics, and IDEALS would truly be an international powerhouse. The expectations of the IDEALS Founding Board were much more modest, hoping to achieve a stable membership of about 500 after 5 years. As mentioned, we have not even come close to this number.

There are other signs that the discipline of dental ethics is still struggling to attain a structural base. Expertise. There exists, to my knowledge, not a single academically based center or institute dedicated to the study and advancement of the field of dental ethics, nor are there any (endowed) chairs in dental ethics. Indeed, the number of individuals globally who hold advanced degrees in both dentistry and ethics has remained very small. I venture to guess that we can count the number of dentists worldwide who also hold a doctorate in ethics on two hands. Ethics committees. There is, as far as I can tell, not a single (university affiliated) dental clinic that has established a clinical ethics committee, akin to the healthcare ethics committees that now exist in every major hospital (at least in North America) and increasingly in other health care facilities as well, such as nursing homes, care facilities for patients with mental disabilities, and rehabilitation clinics. Publications. There still is not a single journal dedicated to dental ethics, nor is there any book series dedicated to this field. In the English language, there are only two dental ethics textbooks available on the US market (from 2002 and 2004), two British textbooks (2002 and 2006), and the recent FDI Dental Ethics Manual. In addition, I am aware of two Dutch dental ethics textbooks (from 1999 and 2002), two Italian (2001 and 2004), one Swedish (from 1998), and one German textbook (2002). I am not aware of any more recent textbooks or any textbooks in other languages, but I do know that most dental publishers are very hesitant to produce books on dental ethics, fearing there is not enough interest to make such productions profitable. Books on more specific topics in the field of dental ethics are even more sparse. Congresses. The bi-annual IDEALS congresses, notwithstanding excellent programming, draw only modest numbers of attendants and many first-time participants do not become permanent members of IDEALS and do not return. Other large international gatherings, such as the annual conference of the American Dental Association which draws crowds in excess of 40,000 attendees, dedicate very little, if any, programming to ethical issues. The same is true for the largest annual dental research conference, organized by IADR/AADR . Occasionally, dental conferences are specifically devoted to dental ethics, but such important events do not appear to result in a sustained engagement in dental ethics.

The aforementioned developments – or rather the lack thereof – is particularly striking in view of the number of dentists worldwide (almost 2 million) and in comparison to the status of related disciplines such as medical ethics and nursing ethics (both of which enjoy strong structural foundations and continue to progress in terms of research, education, clinical impact, and policy development). What explains this difference?

One possibility is that the practice and organization of dental care do not engender a very strong need of ethics research, education and consultation. This may be because dentistry, unlike medicine and nursing, does not entail many ethical dilemmas or challenges – or so the argument would go. Indeed, it has so far happened twice to me that dental journal reviewers of an article I had co-authored on a dental ethics topic rejected it because the ethical challenge we sought to analyze and discuss simply did not exist according to the reviewers.

Another possibility is that dentists do face ethical challenges, but they tend to be very similar to the issues physicians face, except less complex. Hence, the resources developed by medical ethics experts are believed to be sufficient to meet the needs of dental educators, dental policy developers, and those responsible for maintaining dentistry’s professional status. In short, there is no need for the specialized field of dental ethics.

Yet another explanation is that individual dentists as well as the profession of dentistry, maybe more so than medicine and nursing, have always been and continue to be quite able to effectively address whatever ethical challenges have arisen. Dental educators, so the argument would go, have always been very capable of transferring the ethos of the profession to the next generation of dental practitioners without the need of specialized dental ethicists, and codes of ethics developed by the profession of dentistry itself have proven to be sufficient means of guiding the practice.

I am, personally, not convinced that any of these three explanations is sufficient or even correct. But as my experience with some dental journal reviewers has already proven, it does not really matter what outsiders like me believe. Whether rightly or wrongly, as long as the profession itself concludes that there does not exist an urgent or serious need for an expanded investment in the discipline of dental ethics, at least not in comparison to other dental domains that are competing for attention and resources, the discipline will not expand.

As the results of our recent membership survey (reported elsewhere in the Bulletin) show, the majority of IDEALS members actually does believe that IDEALS fulfils an important need and should seek to sustain itself, even with a small membership. Fortunately, our financial status allows us to do so, as long as a sufficient number of members is willing to assist in the management of IDEALS and its projects by serving on the Board and the various committees. The new members who joined the IDEALS board most recently are bound to bring new ideas for new projects and new directions. Let me therefore conclude by thanking those IDEALS members who already came forward and assumed a leadership position, and encourage all other members to follow in their footsteps. The future of dental ethics may yet be bright.

 

Correspondence Address:
 
Jos Welie
Center for Health Policy and Ethics
Creighton University
2500 California Plaza
Omaha, NE 68178 - USA
jwelie@creighton.edu