In the Fall of 2014, the Board of Regents of the American College of Dentists approved a major study of ethics in dentistry. In October 2019, a draft of the comprehensive report was reviewed by the empaneled Project Advisory Group as well as the ACD Board of Regents, who unanimously approved publication in early 2020.
The Board of Regents has referred to this project as a “Gies Report” on ethics in dentistry because it was modeled on the multiyear Carnegie Commission on Higher Education, Bulletin #19, issued in 1926. That study, directed by William J. Gies, used in-depth fact-finding rather than relying on panels of experts and urged that dentistry be grounded in scientific principles. Dr. Gies was the editor of the Journal of the American College of Dentists from its inception in 1934 through 1939.
The first phase of the project was devoted to defining its scope, clarifying methods for gathering information, and building relationships with partners. The project includes: (a) a comprehensive survey of the values in the profession and oral health care—including those of individual dentists, the profession more broadly defined, patients, and society; (b) professionalism and the role of trust; (c) truth claims; (d) standards and alternative concepts of oral health; (e) independence of the profession; (f) commercial influences; (g) the context of changing demographics and social values; and (h) management of conflicting values—identification, reflection, and means used by dentists for getting into and out of problematic situations.
This project was generously underwritten by the late Dr. Jerome B. Miller, past president of the ACD.
In the May 2019 issue of the monthly, The Atlantic, author Ferris Jabr describes an incident where a dentist purchased a practice from a retiring dentist and discovers examples of extensive overtreatment. Patients have been informed and the retiring dentist is under indictment for insurance fraud and is being investigated by the Dental Board of California. The article also describes activities such as evidence-based dentistry, supported by the American Dental Association, and other policies intended to place a strong scientific base under oral health care. The article mentions that these efforts are ongoing and not necessarily understood or applied by all dentists.
The American College of Dentists supports the growing scientific basis for oral healthcare, the professional ideal of service to patients and others who need oral health care, and the responsibility of dentists to help each other achieve these ideals and protect the public.
We, therefore, regard the Atlantic article as an opportunity for reflection on ways to build an even stronger dental profession, grounded in strong science, service, and the mutually shared standards among dentists. We honor those who make patients’ oral health paramount.
It is understood that there are multiple, legitimate perspectives on the material presented in the article. There is an opportunity here to learn by listening to these multiple points of view. It is urged that the article be shared and discussed for what can be learned. In order to facilitate this kind of discussion, the College has developed a set of suggestions for hosting small group discussions among professionals and for interacting with patients who may have read the article. These listening tools are posted below this response. These are not prescriptive statements; they are suggestions for building stronger relationships among dentists and with patients.
The Northern California Section of the college, University of the Pacific, and UCSF SPEA chapters, as well as those dental schools held a workshop on how to discuss unwelcome news. This video contains interviews involving dentists and a patient concerning the Atlantic article on overtreatment
The Officers and Regents of the American College of Dentists
Journal of the American College of Dentists
Winter 1996, Volume 63(4), pages 19-21
Managed care is a market mechanism for distributing oral health care resources. There are four essential features which together define managed care:
There are eight characteristics of managed dental care that seem to be emerging, which although they do not define managed care, are usually the focus of discussion:
The aspirational statements of the American College of Dentists are a voluntary set of ethical guidelines that all Fellows of the College hold as goals in their professional lives.
A Fellow of the College will …
It is the position of the American College of Dentists that ethical practice takes precedence over features of any particular system of delivering or paying for care. Managed care can be viewed in the context of ethics; the opposite is not meaningful. The core aspirational values of the College are identified in bold in the following analysis of managed care.
Managed care is a market mechanism. Dentists and patients participate out of the same motivation as purchasers and carriers–economic advantage. Although ethical abuses might be caused by participants in such a system, in theory, the system is neither good nor bad. However, to protect against moral risk, the following principles are considered primary:
“A. The ethical and professional aspects of dentistry must always take precedence over its economic ones. The market nature of managed dental care must always be evaluated in an ethical and professional context; whereas the reverse is not meaningful.”
Although managed care per se might be regarded as ethically neutral, it does confront the profession with increased levels of ethical risk. Increased vigilance is necessary in order to avoid the ethical compromises associated with maintaining different standards of care for patients on different payment systems, passing the costs of bad business decisions on to patients, and failing to fully disclose pertinent information to patients, for example. The principle of justice would be violated if it were found that managed care distributed oral health care in an inappropriate manner or that it lowered the overall level of care provided (as would be the case if chronically low levels of compensation undermined the research foundation or reduced the number of care providers).
The most serious of the ethical risks to which managed care exposes the profession concerns autonomy of the patient, the dentists, and to some extent the purchaser. Autonomy encompasses individuals’ free choice of their own futures, subject to not causing harm to others. It remains to be determined by ethical analysis whether the restructuring of large segments of the health care system based on aggregate patient characteristics is in conflict with the ethical principle of autonomy. Coercion–forced choices between avoidable undesirable alternatives–and withholding or distorting information are factors contributing to limited autonomy. Veracity is also a related ethical risk.
“B. It is unethical to participate in care programs that require the dentist to knowingly coerce patients or limit the information available to them for making informed decisions about their care.”
The dentist-patient relationship is often altered in managed care arrangements, and incidents have been reported of attempts to Justify substandard dentistry based on terms imposed by managed care contracts. At this time there is no conclusive evidence that dental care delivered in managed care settings is different in quality from care delivered in traditional systems. The potential for under treatment represented by selection of care based on coverage rather than need, failure to diagnose, use of inferior materials or performing careless work, rationing access to care, or delegating to unqualified support staff is real. But this risk is not inevitable—it is always mediated through the dentist’s personal choice of standards of care. Economic self-interest should not be placed higher than the aspirational goals of compassion, justice, and beneficence.
“C. The standard of care must be the same for all patients regardless of the means of reimbursement available to patients.”
It is possible that dentists may discover themselves in contractual arrangements that force a choice between compromised patient care and personal economic loss to the dentist. If this situation arises because the dentist was mislead or defrauded by a carrier, appropriate legal action against the carrier should be followed, always with the help of competent legal advise and the support of the profession (professionalism). If the unsound contractual arrangement resulted from the dentist making a decision that was not fully informed, both the dentist and his or her patents have been put at risk by the dentist’s negligence. The concept of competence in dentistry extends to the safety, personnel, financial, and other areas of dental practice, as well as to technical matters. Because the dentist assumes personal responsibility for providing care under the terms of all reimbursement systems accepted in the office, diligence in selecting such programs is also the dentist’s responsibility.
“D. It is an ethical obligation to fully explore and understand all terms of contractual arrangements and their implications for practice prior to committing to them.”
Managed care cannot be used in any way to shift responsibility for patient care from the dentist. The basic tenants of veracity should prevent one from justifying substandard care by pointing to other’s rules. Especially disturbing would be any attempt to involve or use others in such a system.
“E. Employing or directing underqualified individuals in order to profit from a lower standard of-care offered to patients in a managed care system is inherently unethical.”
The emergence of managed care has created division within the profession. Differences in the relative importance of values intrinsic to the profession, actual and perceived competition among practitioners, and uncertainty about how the profession should respond collectively have caused undesirable tensions among dentists. While the choice to participate, the nature of participation, or the choice of not participating in managed care systems is a personal matter, there are some ethical obligations that apply to dentists not involved with managed care.
Professionalism and tolerance are clearly established principles in dentistry. The American Dental Association Principles of Ethics and Code of Professional Conduct lays out guidelines for criticizing the work of colleagues. The aspirational principle of tolerance applies in such cases as well.
“F. Dentists shall be obliged to report to the appropriate reviewing agency as determined by the local component or constituent society instances of gross or continual faulty treatment by other dentists. Action is required because the patient’s oral health is being threatened and not because of the nature of the reimbursement system.”
Patients have a right to know why their dentists choose not to participate in managed care systems. It is as important to carefully think through one’s position to avoid managed care as it is to evaluate offered contracts. This is the essence of integrity. It may even be appropriate to present this professional position in writing. A personalized variant of the following position would convey a professional respect for patients’ health and dignity without maligning managed care.
“G. I believe in providing the highest level of care possible to my patients. After carefully studying the plans available as supplements for patients’ responsibility for their own health, I have not found any which permit me to offer the level of care I believe my patients are entitled to. I would be pleased to discuss various plans and alternatives with you.”
Managed care is an issue facing the profession as well as individual dentists. While single practitioners cannot be relieved of their personal responsibility in patient care, there are several aspects of an altered economic system for allocating oral health care that can only be addressed at a larger level. In fact, one of the characteristics of managed care is its emphasis on aggregate rather than individual markets. Another feature of managed care is the involvement of four parties in place of the customary dentist-patient dyad.
The economic interest of carriers and purchasers call for one kind of regulation of quality while health concerns of dentists and patients call for a different type. The principles of integrity and competence require that dentists retain full responsibility for defining, monitoring, and enforcing technical dental standards of care. Professionalism can be used to justify the obligation that the profession as a whole engage in cooperative evaluation of the economic and patient satisfaction aspects of care.
“H. Organized dentistry and other groups concerned with oral health should actively engage managed care carriers and purchasers to create systems for ensuring appropriate economic and patient satisfaction outcomes and develop or enforce existing regulations to protect the quality of oral health of patients.”
Managed care is based on a number of assumptions about the relationship between oral health and cost factors that have not so far been supported with adequate data. Specifically, the following hypotheses stand in need of verification (veracity):
“I. The profession should both focus issues critical to the evaluation of managed care and gather, interpret, and disseminate research bearing on these questions.”
The emergence of managed care is heightening the importance of several issues already recognized as being especially important to the profession and the patients it serves. There is a history of progress in each of the following areas:
“J. The profession should refocus on the traditionally important roles of serving dentists through treatment outcomes data, standards of care, business training, advocacy for patient oral health, training in ethics, and forums for policy issues in order to improve oral health of patients.”
The Board of Regents of the American College of Dentists
Excerpted from the Journal of the American College of Dentists 70(3):6-8, 2003
The American College of Dentists encourages ethical dental practice and actively opposes quackery, charlatanism, fraud, incompetence, and any other corruption of oral health care that places patients at unnecessary risk and threatens the integrity of the profession. The College also supports the advancement of the profession, especially continuous growth of the capacity of individual practitioners to provide effective, predictable outcomes deemed desirable by patients and the public.
While the vast majority of dental care is of high quality, a few individuals have abused the rights and privileges of the profession by misrepresenting the services they provide. Gross mistreatment of patients includes fraudulent billing, practicing without a license, and subjecting patients to dangerous and unproven treatments. Abridging trust can also take the form of gaps in competence and shading informed consent to favor procedures preferred by the practitioner. The College challenges the profession to study and understand the nature and damage of these unethical practices and to take appropriate action to eliminate them.
Ethical dental practice meets all of the following standards. Where one or two of the standards are imperfectly met, the practice is ethically questionable. Quackery and fraud are marked by clear and regular failure to meet any of these standards.
The accompanying table shows the characteristics, consequences, and some examples of ethical and questionable practice, and of quackery and fraud. Among the types of quackery and fraud, it is possible to identify distinct patterns of practice that damage patients and the profession, including:
Quackery and fraud can be the result of several motives, most commonly a desire (whether recognized or not) for status or income on the part of the dentist. Even when quacks and frauds believe they are acting in the best interests of their patients, they make the mistake of setting themselves up as the sole judge of their actions.
Although quacks and frauds are directly compromising patients, certain actions are required of ethical dentists. These responses are the result of dentistry’s obligation to protect patients and to preserve the reputation of the profession. Because quacks and frauds damage both individual patient’s and the public’s trust in dentistry, specific actions are necessary on the part of individual dentists toward their patients and toward their colleagues, of the profession generally, and of the research community.
Improving the patient’s overall oral health and well-being through means understood and approved by the patient, other dentists, and society
Quality, patient-centered treatment within standard of care
Innovative aspects of practice that meet the five standards of ethical practice
Experimental practice (research) that meets Institutional Review Board standards
Almost all established dental practices, those that remain on the leading edge through professional procedures development, approved research programs
Placing the patient at risk for decreased overall oral health and well-being for the dentist’s benefit
Performing procedures that the patient, other dentists, or society would not choose if well informed
Performing procedures at marginal levels of quality or failing to provide necessary treatment
Failure to take reasonable steps remain current in knowledge and skill and awareness of prevailing standards of care
Overtreatment, undertreatment, poor quality care, lack of comprehensive care, failure to diagnose, misrepresentation of patient benefits, failure to refer when case exceeds skill
Damaging the patient’s overall oral health and well-being, undermining the public’s trust in dentistry as a profession, or breaking applicable laws
Withholding or distorting relevant information about treatment options, probable outcomes, or history of previous outcomes from patients, colleagues, or society for personal gain
Knowingly performing procedures that do not meet the standard of care
Practicing without a license, practicing medicine or other health profession on a dental license, billing for procedures not performed, gross continuous substandard care, misrepresentation of one’s qualifications, distorting the scientific basis of dentistry