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.

The Nature of Quackery and Fraud

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.

Ethical Dentists Must Respond

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.

Responsibilities of Individual Dentists to Patients

  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.

Responsibilities of Individual Dentists to Other Dentists

  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.

Responsibilities of the Profession

  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.

Responsibilities of the Oral Health Care Research Community

  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
Ethical PracticeQuestionable PracticeQuackery and Fraud
Consequences
Improving the patient’s overall oral health and well-being through means understood and approved by the patient, other dentists, and societyPlacing the patient at risk for decreased overall oral health and well-being for the dentist’s benefitDamaging the patient’s overall oral health and well-being, undermining the public’s trust in dentistry as a profession, or breaking applicable laws
Characteristics
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

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

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

Examples
Almost all established dental practices, those that remain on the leading edge through professional procedures development, approved research programsOvertreatment, undertreatment, poor quality care, lack of comprehensive care, failure to diagnose, misrepresentation of patient benefits, failure to refer when case exceeds skillPracticing 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