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Ethics Report: The New Professionalism

Gies Report 2020: Perspectives on Dental Ethics for a New Century

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.

The College Responds to the Atlantic

The American College of Dentists Responds to the Atlantic article, “The Truth About Dentistry”

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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

Managed Care

Dental Managed Care in the Context of Ethics

The Officers and Regents of the American College of Dentists

Reprinted from

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:

  1. It is a secondary market; dental health care opportunity, not care itself, is brokered in the managed care market. In this fashion it might best be termed “brokered care” since future dental visits are actually bought and sold rather than oral health itself
  2. It is a four-party system; there are (a) patients, (b) dentists [together comprising the primary market], (c) brokers, and (d) purchasers [the latter two comprising the secondary market].
  3. Costs and benefits are calculated in the aggregate; not on an individual basis. Plan purchasers buy a package of benefits. Third parties work on an actuarial basis. Dentists cannot use conventional per-procedure accounting to figure their return; only aggregate marginal analysis works.
  4. Some of the dental health care dollars are shifted from providing care to managing the market.

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:

  1. Income of providers tends to be lowered
  2. Income of brokers tends to rise
  3. Cost to purchasers tends to be lowered
  4. Risk is spread more evenly across the four parties
  5. Access to care among the marginally served tends to be increased
  6. There are pressures for standardizing dental care
  7. Large databases on care delivery are being assembled by third parties
  8. More opportunities for ethically based decisions are created for dentists

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 …

  1. Value truthfulness as the basis for trust in the dentist-patient relationship (Veracity)
  2. Treat all individuals and groups in a fair and equitable manner (Justice)
  3. Recognize the dignity and intrinsic worth of individuals and their rights to make choices (Autonomy)
  4. Respect the rights of individuals to hold disparate views in ethics discourse and dialogue as these views arise from diverse personal, ethnic, or cultural norms (Tolerance)
  5. Be sensitive to and empathizes with individual and societal needs for comfort and help (Compassion)
  6. Strive to achieve the highest level of knowledge, skills, and ability within his or her capacity (Competence)
  7. Be committed to involvement in professional endeavors that enhance knowledge, skills, judgment, and intellectual development for the benefit of society (Professionalism)
  8. Act in the best interests of patients and society even when there are conflicts with the dentist’s personal self interest (Beneficence)
  9. Incorporate core values as the basis for ethical practice and the foundation for honorable character (Integrity)

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):

  1. The cost of introducing a market intermediary is less than the improvement in overall oral health that such an intermediary introduces.
  1. It is possible to reduce variation around the least expensive acceptable alternative sufficiently to avoid the damage caused by random undercare.
  2. Market-driven reimbursement patterns across the range of service, including diagnosis and prevention, match the optimal allocation of care.
  1. The benefit of aggregate decrease in overall level of excellence of care to acceptable levels will be offset by greater aggregate utilization rates.

“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:

  1. Valid and interpretable information about the outcomes of treatment.
  1. Standards of care that are uniform enough to provide guidance and flexible enough to accommodate patient individuality.
  2. Training of dentists in business and interpersonal skills sufficient to support practices based on quality dental care for patients.
  3. Advocacy for patient oral health at the individual and group levels.
  4. Training of dentists in the ethics of the dental profession.
  1. Forums for the presentation and debate of issues critical to the oral health of America.

“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.”



  1. Beauchamp R, Childres. Principles of biomedical ethics. Oxford, UK: Oxford University Press, 1994.
  2. Etheredge L, Jones S. Managing a pluralist health system. Health Affairs, 1991;10:93-105.
  3. Henikoff LM. Purchase-driven reform: who is at the wheel? Frontiers of Health Services Management, 1993;9:7-4 1.
  4. Iglehart JL. The struggle between managed care and fee-for-service practice. New England Journal of Medicine, 1994;331:63-7.
  5. LaPuma J, Schiedernmayer D. Ethical issues in managed care and managed competition: problems and promises. In Nash DB (ed). The physician’s guide to managed care. Gaithersburg, MD: Aspen, 1993. Pp 31-60.
  6. Ozar DT, Sokol DJ. Dental ethics at chairside: professional principles and practical applications. St Louis, MO: Mosby, 1994.
  7. Peligrino ED. Healthcare: reform, yes; but not a la Lamm. Cambridge Quarterly of Healthcare Ethics, 1994:3:168-72.
  8. Priester R. A values framework for health system reform. Health Affairs, 1992; 1 1:84-107.
  9. Rule J, Veatch R. Ethical questions in dentistry. Chicago, IL: Quintessence, 1993.
  10. Schlackman N. The impact of managed care on clinical practice. In Bloomberg MA, Mohlie SR (eds). Physicians in managed care: a career guide. Tampa, FL: The American College of Physician Executives, 1994. Pp 27-43.
  11. Shortell SM, Gillies RR, Anderson DA. The new world of managed care: creating organized delivery systems. Health Affairs, 1994; 13:46-64.
  12. Sroline, AM, Weiner JP. The new medical marketplace: a physician’s guide to the health care system of the 1990s. Baltimore, MD: The Johns Hopkins University Press, 1993.
  13. Volpe FJ. Types of managed health care organizations. In Bloomberg MA, Mohlie SR (eds). Physicians in managed care: a career guide. Tampa, FL: The American College of Physician Executives, 1994. Pp 7-26.
  14. Weinstein BD. Dental ethics. Philadelphia, PA, 1993.

Quackery and Fraud

The Ethics of Quackery and Fraud in Dentistry:
A Position Paper

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.

  1. Informed consent: patients make free choices from among alternatives that are explained impartially in language they understand.
  2. Benefit and risk: net expected benefit to patients must outweigh anticipated risks.
  3. Competence: practitioners have the knowledge and skill expected by patients and the public to be able to produce results that meet the standard of care and the expectations created by dentists.
  4. Professional integrity: practitioners maintain the trust patients and society have placed in the profession.
  5. Reasonable scientific base: practitioners should be able to give reasons for their actions that are acceptable to their peers.

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:

  1. Incompetence: practicing beyond one’s capabilities.
  2. Using patients as a means rather than an end: overtreatment to enhance one’s reputation or income and undertreatment to increase profit.
  3. Unqualified practice: practicing beyond one’s license, including the practice of medicine on a dental license.
  4. Quackery: risky and inappropriate treatment caused by practitioners who mislead patients because they mistakenly believe the treatment is appropriate.
  5. Charlatanism: risky and inappropriate treatment caused by practitioners who intentionally mislead patients for personal benefit.
  6. Fraud: purposeful and knowing misrepresentation, withholding of information, or selective reporting of information for personal gain.

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.

  1. Ethical dentists should practice at an ever advancing level of knowledge and skill but maintain an acceptable level of risk to benefit their patients.
  2. Ethical dentists should be familiar with popular unsubstantiated practices in order to discuss these intelligently with patients.
  3. Ethical dentists should provide the most positive available approaches, even when unfavorable prognoses are found, in order to discourage patients from seeking unsubstantiated care out of a sense of hopelessness.
  4. Ethical dentists should seek to maintain the relationship of primary care provider, even if patients consult others of whom the dentist disapproves.
  1. Ethical dentists have a responsibility to understand the approaches and capabilities of practitioners whom their patients are likely to see.
  2. Ethical dentists have a responsibility to discuss their concerns with other caregivers if there is a suspicion about questionable practice, quackery, or fraud.
  3. Ethical dentists should alert their colleagues to unconventional practice.
  1. The profession has a responsibility to protect patients by taking actions against the licenses of practitioners whose habitual mode of practice damages patients.
  2. The profession has a responsibility to encourage a broad understanding of risk, risk factors, and practices that expose patients to unnecessary risk.
  3. The profession should promote means of sharing, within dentistry, information that promotes quality care.
  4. The profession has a responsibility to inform the public regarding the benefits of good oral care, properly provided.
  5. The profession has a responsibility to inform policy makers about the standards of oral health care, the dangers of inappropriate care, and ways of distinguishing quality care.
  1. Research should be conducted only in a manner widely understood as exposing patients to an acceptable level of risk.
  2. Research should be reported in a manner that promotes free exchange of valid information, accurately communicated.
  3. All professional journals should use the form and conventions appropriate for reporting research to ensure accuracy and completeness, and never attempt to create an impression of scientific quality for commercial purposes.
  4. Practitioners should be taught to combine scientific evidence with systematic outcomes data from their own practices in order to form accurate estimates of the levels of risk their patients are exposed to in individual practice.

Categorizing Ethical Practice, Questionable Practice, and Quackery and Fraud


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