is dentistry a profession part 1

8/8/2019 Is Dentistry a Profession Part 1

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R O F E S S I O N A L I S S U E S

Is Dentistry a Profession?

Part 1. Professionalism DefinedJos V.M. Welie, W e d s , JD, PhD *

A b s t r a c t

Individual dentists and organized dentistry alike invariably claim to be (members ofl a profession. This label is cher-ished because it suggests special social, moral and political status. However, almost every self-respecting occupa-tio n nowadays claims to be a profession. Hence, the question arises as to what exactly is meant when dentists claimto be professionals and, more important, whether they can justifiably lay daim to this label. Rather than reviewingthe manifold and divergent discussions in the literature about professionalism, the author proposes - n this first of3

consecutive articles-

definit ion of the term "profession" that is based on the literal origins of the word. Next,it is argued that a profession arises out of a social contract between the public and a service occupation thatprofesses to give priority to the existential needs of the people served. In the second article , the author deducesseveral professional responsibilities. The third and final article examines whether and to what extent dentistry fulfillsthese responsibilities and outlines some future challenges.

MeSH Key Words: dental care/standards; dentist-patient relations; ethics, dental; professional practice/trends

Q I Can Dent Assoc 2004; 70(8):529-32This article has been peer reviewed.

Idividual dentists and organized dentistry alike invari-

ably claim to be (members of) a profession. This label is

cherished because it suggests special social, moral andpolitical status. It has a nice ring to it and is likely to instilltrust among the public at large and a dentist's clientele inparticular. However, almost all self-respecting occupationsnowadays daim to be professions, issuing "statements ofcore values" or even "codes of ethics." Codes hwe beendrafted by such diverse occupations as advertising, chiro-practic, computing, direct marketing, fund-raising, lawenforcement, lobbying, mining, the ministry, newspaperediting, organ playing, pharmacy, realty, social work, triallaw and, of course, dentistry.l.2 Is the label "professional"simply synonymous with other, less eloquent adjectivessuch as "competent," "reliable" or "decent"? E any person

who does what he or she has agreed to do, and does it well,a professional? Is any occupation that issues a list of do's anddon'ts a profession? In this series of 3 consecutive articles,we will'attempt to answer these questions. Doing so &strequires a conceptual analysis of the term profession,"which is the main objective of this first artide.

Professionalism DefinedConsultation of contemporary dictionaries such as the

American Heritage Dictionary, the Concise Oxford

Dictionmy and the O&d American Dic tiomty of CurrentEngfishd ield 1 of the following 3 rather diverse defini-

tions of a professional:( I ) A person who, unlike a volunteer, gets paid for work

performed.(2) A person who, unlike an amateur, has the training or

expertise to do the job competently,(3) A person who, unlike a lay person, has been initiated

or ordained into the Mowship or guild that holds an exdu-sive monopoly on the particular line of work.

Given the large number of paid occupations thatdemand several years of advanced education and some kindof certification or licensing, today's liberal use of the labels"profkssion" and professional"is understandable. But asthese labels are claimed by ever more people to cover ever

more occupations, their discriminative force will begin todecrease. At some point in the future, they may lose theircachet altogether, and people will begin to look for new,more distinctive attributes.

At present, however, these labels still carry special signifi-cance. They are popular precisely because they are loadedterms. They suggest unusually hlgh levels of expertise andskillfulness, virtuousness and trustworthiness, as well associal status, class and market value. The question thus ariseswhether the claim to be a profession(al) is always warranted.

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The answer to this question lies in responses to a f wmore specific queries. First, by what criterion or criteria canwe judge whether a particular occupation (such as dentistry)qualifies as a ~rofession? ypically, halfa dozen hallmarks arelisted, and occupations meeting all or at least most of themare considered professions. Frequently identified hallmarksindude a skill based on theoretical knowledge obtainedthrough extended and standardized education, demon-strated competence, high l e d of organization, codificationof behaviour and altruism.3.4 But why these particular traits?What is the common denominator among these characteris-tics that sets them apart from, say, indoor location, creativ-ity wearing of a uniform, use of hlgh levels of communica-tion, and restriction to women? The particular choice ofhallmarks is often defended by reference to some occupationthat is assumed to be a profession, typically medicine. Butthis defence invokes a circular "gument, for why is medi-cine considered a profession? To characterize medicine as aprofession, a definition of a profession and the criteria ofprofessionalism must already be in place.

Instead of relying on the copmon and arbitrary use of theterrn "prohional," this artide proposes a definition of the

claiming to be professions did so first and foremost to protecttheir own interests, specificdy financial ones.4 In a recentarticle, Bertolami5 bluntly admits that "physicians anddentists do not place the patient's welfare b h r e their own."Indeed, when their interests conflict, patients and dentistsalike "can be reliably counted on to place themselves first." Inshort, the ethical principle that "the patient's needs mustcome before the needs of the practitioner . . s a noble senti-ment; it is also untrue."5These words, coming-from he deanof a U.S. dental school, underscore Kultgen's6 warning thatthe alleged service to humanity is the 'Vrmythos" fromwhich all of the myths about professions spring. However,the present series of artides does not strive to provide a histor-ically correct overview of the development of proksions;rather, it a ims to outline an ideal worth striving toward.

The profession's profession is an unusual commitment.Human beings are by their very nature tempted to act fortheir own good, giving preference to their own interestsover those of others. This egoistic trait is rooted so deeplythat most legal systems excuse people who harm or killothers in self-defence. Capitalist free market economies arebuilt on this human trait, and some philosophers have

term '$roksion" that goes ba& to the argued that se~ishn-ess is actually aliteral origins of the term. In conjunc- I virtue.7 I t therefore behooves any occu-tion with-this more restrictive definition, I pation that defines itself as essentiallya much more stringent set of criteria will altruistic, rather than egoistic, tobe M o p e d in the next artide that An oc'?~ation canMt demand from its members that theysignificantly limits the number of occu- simp& publicly commit to this ideal. For,pations that can daim to be professions unlike charity, professional altruism isproper. In hct, it will be argued that S M m * T hat s t a m m m t be not an option but an obligation thatompations that have traditionally been granted 6 , he p d & c . binds each and every member, individ-considered professions could lose that

Ially and collectively.

label. As will become dear in the third The public, having been promised

article, dentistry is among those at riik altruism rather than egoism, enters intoHowever, this "risk" is not moral in a kind of mutual agreement, also called

nature. Precisely because the term "profession" is being a "social contract," with the profession, granting it suchdefined very narrowly, not being a profession or a profes- perks as a monopoly, above-average income and socialsional does not equate with being incompetent or immoral. status. But why is such a "deal" of interest to the public? OfFor example, it will be argued that the ethos of business is course, it is always nice to be treated altruistically, but if theincompatible with that of a profession. Hence, being a busi- price is too high it may not be worth it. For example, grant-nessperson predudes a person from being a professional. ing a monopoly means there is no competition, whichBut the ethos of business leads to ethical principles and could lead to reduced quality of service and higher fees.rules that a businessperson must abide by in order to act Most Western societies abhor monopolies and have createdmorally in the business context. It does not matter whether governmental watchdogs (such as the U.S. Federal Tradethe businessperson violates professional ethical rules, Commission) that protect the public against their dangers.because those rules do not bind him or her. Conversely, a How then does a particular collective of service providers,

person cannot enter a profession and retain the expanded professing to act for the good of the public, convince themoral freedom of a businessperson. public to enter into such an exclusive social contract?

The Profession's Profession Human Frailty and VulnerabilityThe term $rofessionJ' literally means a 'hublic avowal." An occupation cannot simply claim professional status.

The term does not speufy what it is that those professing That status must be granted by the public, and the public willprofess to, what it is they promise and commit (not) to be or enter into the necessary social contract only if the servicedo. However, it is generally assumed that professionals offered is of vital importance. For example, if the product orprofess to protect and foster "the benefit of the public." service offered is much desired but not really needed, if it canGranted, there is ample historical evidence that occupations always be postponed or even forgone, there is no reason to

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Professionalism Define d

enter into a social contract with those professing to providethe service. The same is true if the good or service can asilybe obtained without relying on the service providers.However, a good reason for the public to enter into a socialcontraa - aybe the only good reason - s existentialvulnerability. Existential vulnerability arises out of thecombination of a significant human need that must berelieved and complete dependency on experts for that relief.

We like to think that we have control over our own lives,determine its course, fashion a style, plan a career, shapeour bodies, advance our minds, choose a fiith. But in real-ity we have very little fieedom. We do not choose to beborn, nor do we choose when or where our births takeplace. We have no say in our parents, our naming or ourraising, and little say in our subsequent education.Although as adults we are free to convert, it is alwaysconversion from the fii th of our parents and the religiousconvictions prevalent in the culture with which we grew up.Even in a democracy we have little impact on our govern-ment, yet are fully dependent on it for protection againstviolence from within and abroad. We are surrounded bydangers to our health that can strike at any moment. Andwe must all die at some point.

Not a ll of the needs listed above render us vulnerableand dependent on others. For example, as adults, we cantake charge of our own learning, but during childhood, wedepend on the educational expertise of teachers. We cangenerally overcome the sorrow and emptiness that fbllowthe death of a beloved partner, but the loss of all of one'sfamiiy in a single terrorist attack may be too much to bearand may necessitate psychological and spiritual help fromexperts. We can ourselves arrange for clothing to protectagainst the elements, but if a toothache strikes or we break

a limb, we have to rely on expert dental and medical care,trusting that our health care providers will not abuse theirpower in their own interests. This trust is warranted by theprofession, i.e., the public promise by the service provideralways to give priority to the interests of those served overself-interest.8

We can hus define a profession as a collective of expertservice providers who have jointly and publicly committedto always give priority to the existential needs and interestsof the public they serve above their own and who in turnare trusted by the public to do so.

The Social Contract

As mentioned earlier, an agreement between the profess-ing profession and the entrusting public can be character-ized as a social contract. This is a somewhat confoundingterm because there is no piece of paper or any other tangi-ble evidence of the existence of this contract. There iscertainly no document specifying the terms of the agree-ment. "Social contract" is merely philosophical jargon, anattempt to explain certain structures in society by analogyto legal contracts between individuals. Codes of ethics andpublic pledges do not automatically result in the kind of

social contract that establishes a profession proper.Conversely, the absence of a written declaration or oathspecifying the responsibilities of the profession and therights of the public does not n* the social contract.Such documents can support the social contract, but theydo not constitute it. Thus, the fact that physicians, but notdentists, typically swear an oath at graduation does notprove that physicians are professionals and dentists are not.

Not only is there no piece of paper clearly specifying theterms of the social contract, but there are no clearly identi-fiable parties to the contract. "The public" is not an entitythat can, as such, make agreements. At most, the public canenter into contracts via its representative government,specifically the legislative branch of government.Conversely, there is no specific entity that ca n claim to be aprofession. The collective of all dentists does not act assuch. Even within a single country, there may be manyassociations claiming to represent dentists. For example, theUnited States is home to the American Dental Association,the National Dental Association and the American Collegeof Dentists, to mention only 3 national associations. Noneof these organizations has real representative power. Atmost, they can speak on behalf of the dentists who volun-tarily joined or were selectively admitted. Furthermore, if aparticular dentist violates the terms of the social contract,these organizations have virtually no power to rectify thesituation. That power lies with the dental board in eachstate. However, these boards do little other than licensedentists. They do not organize dental education, developtreatment protocols or optimize access to oral-health care,to mention only 3 responsibilities that the prokssion ofdentistry is charged to ful6ll by virtue of its status as aprofession. (This topic will be discussed in more detail in

the next article in this series.)The absence of clearly identifiable parties to the social

contract and the absence of a written agreement specifyingthe terms mean that the social contract between professionand society is dynamic. It continuously changes, grows,matures and adjusts to the circumstances of time and loca-tion. It is always open fbr discussion and new interpreta-tions by the members of the prok sio n itself, as well as bymembers of the public. Hence, a professional code of ethicsthat has not changed for 50 years has little merit, and apledge made at graduation but never again reflected uponhas little relevance. The profession as a whole and eachindividual professional must continually revisit their own

"profession" and reinterpret the terms of the resulting socialcontract with the public lest the contract slowly petrify.

ConclusionsRecognizing the ever more liberal use of the label

'profession" and hence the ever less discriminative force ofthe term, this article began by proposing a definition of"profession" that goes back to the literal origins of the term:a profession is a collective of expert service providers whohave jointly and publicly committed to always give priority

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to the existential needs and interests of the public they serveabove their own interests, and in turn are trusted by thepublic to do so. This agreement between service providersand the public can be characterized as a social contract, theterms of which will be outlined in a subsequent article.However, it is important to remember that, in final analy-sis, the ethical foundation of a profession is the profession,the voluntary promise to care for those fellow humans whoare vulnerable and in need. No dentist was forced toembark on a dental education. No dental graduate wa sforced to his or her commitment to the public. Eachchose to do so voluntarily. +

Acknowledgement: The resear& toward this article was snpported inpart by a p t rom the NI DC R (1 R21 DE014969-01).

Dr. Welie is professor, Cen ter for Health Policy andEthics, and department of commnnity and preventivedentistty, Creighton University Medical Center,Omaha, Nebraska.

Correspondence to : D,: 0s Welie, Center for Health Policy andEthics, Cr ei dt on Uni venit y Medical Center. 2500 California Pkzul,O d , E 68178- US A. E-mail: [email protected].

The views expressed are those of the anthor and do not necessarilyrejlect the opinions or official policies of the Canadian DenulAssociation.

References1. Gorlin RA. Codes of professional responsibility: ethicssrandards inbusiness, health, and law. 4th ed. Washington: Bureau of Natio nalAffairs;

1999.2 . For an extensive lisring of codes online, organized by24 occupationalcategories, see Center for the Stud y of Ethics in the Professions. U no isInstitute of Technology. Codes of ethics online. Available &om:URL:h n p : l l w w w . i i t . e d u / d e P a m e n t s I c s e p l P u b l i c .3 . MillersonG .Th e qualifying associations: a studyin professionabation.London: Routledge andKegan Paul; 1964.4. Freidson E. Profession of medicine: a st udy of th e sociology of appliedknowledge. Chicago: University of Ch icago Press;1988.5 . Benolami CN. Wh y our ethics curricula don't work.J D c n t Edw 2003;68(4):414-25.6 . Kultgen J . Ethics and professionalism. Philadelphia: University ofPennsylvania Press, 1988.7 .Rand A. Th e virtue of selfishness: a new concept of egoism. New York:Signet; 1964.8 . SwidcHM. oward a normative definition of m edical professionalism.AcadMcd2000; 75 (Q: 612 4.

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is dentistry a profession part 1

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