Is dentistry a business or is it a service? This question has no one correct answer, I imagine most would suggest that it sits somewhere on a spectrum between the two. The issue of whether dentistry is a commercial venture, where we see clients or a professional service where we see patients is difficult. I dislike the notion of thinking of patients as customers or clients as it takes away the fact that as caregivers, we really do have an ethical obligation to treat those in need, regardless of an ability to pay. I remember being taken to task by an ethics lecturer for arguing against this when I was a student. I very much liked the idea of seeing customers and giving as much care as was paid for. Fortunately for my patients and myself, I’ve come to be a firm supporter of our position as healers first with our business interests coming second.
One thing I have become acutely aware of is the rise and rise of peripheral business interests within dentistry. There are those without our ethical and professional obligations who wish to carve out a living by providing a service to our profession.
Take this magazine for example; it isn’t owned by a dentist, but it serves to furnish a need for discussion, with those writing seeking to inform, and it acts as a platform for other products and services wishing to advertise their services to the profession. There’s nothing wrong with that, if people don’t want it, they won’t have it and similarly, no one would be right to
say that it was unfairly coercive in wanting to affect the way patients are treated or care is given.
As you can see, I’m not against capitalism within dentistry, some of the ideas I come across I wish I had thought of and part of me is glad that somebody, somewhere is reaping the rewards for it, dentist or not. There are some however that I feel overstep the mark, they become incentivising or coercive to compromising patient care. For example, I was approached
recently by a company that offered to find patients for me. One of the perks that they offered was that they would take a history of a patient’s complaint and go through the treatment options for me, referring me the patient to have a secondary conversation and provide the treatment. Sounds good hey?
No, it isn’t good. They are effectively trying to encourage the out-sourcing of the consent process. The objective they had would be to increase patient awareness and increase their choice. Laudable as an idea, but sadly deficient in pragmatism - the likely situation would be that the dentist being referred to would need to repeat the whole process themselves. The case of Deriche v Ealing Hospital NHS Trust shows us that the assumption of informed consent is ill-advised. In this case, an obstetrics consultant was found to have breached his duty of care in assuming that the consent process undertaken by a junior colleague was satisfactory. As a result, the claimant’s baby was born severely disabled. Whilst this is far removed from our practise of dentistry, the legal principle remains the same.
This is just one example of a situation where a commercial company has tried (albeit with the best of intentions) to jump in and interfere with a clinical duty that if something went wrong, could land a dentist in rather hot water indeed. Very few commercial interests would ever go into a situation looking to create issue or to cause trouble, in fact, if you ask them about this concern, they are always very quick to reinforce that the duty lies with the dentist to check that all is OK and above-board. It is my experience that the law that applies to dentistry is often poorly understood and can be misinterpreted or twisted to suit, until of course a case goes to the real legal experts. Every dentist has a duty to their patients and there becomes a real risk of this duty being breached if we allow non-professionals to interfere with this in any way.
As we move away from a system where the state catered for all dental needs, we will find the commercial interests that look to profit from the profession becoming ever more present. This is not a bad thing; I couldn’t do my job without the programmers that update my computer practice software or the people who make my instruments, but we need to be vigilant to those that might inadvertently damage the sacrosanct relationship we have with our patients.
I was forwarded a flyer that had been sent round by a local laboratory. ‘UDA Buster Special’ was emblazoned proudly across
the title, it was for budget biteraising appliances at a knockdown price. Although the content of the flyer spoke of providing the best for patients, the real motivation was quite clear from the title. The question in this has to be who is at fault here? On first instance it is quite easy to blame the lab. But actually, it is us as dentists who are at fault for this kind of practise. We should be better than to create a market for those willing to take advantage of unethical practices. If we all worked in an ethical manner, if we all had uncompromising scruples then there would be no room for those peripheral to the pure practise of dentistry to further muddy the waters of ethical practice.
The other guilty partner in this is the NHS system. If the NHS did not push the profession to complete targets that are further and further beyond the reaches of ethical practise then there would not be a need to have such offers. I do not believe that NHS practise is unethical - but it is becoming harder to make an honest living and complete targets in a way that is purely in patients’ interests. At the end of this, whilst there is fault with the NHS system, it was the dental profession and our professional bodies who were prepared to accept this.
Looking to the future it is important that we retain the control to be able to resist the sometimes self-interested pressures of commercial outsiders within dentistry. There is a real problem with simply accepting what nondentists tell us is in the best interests of our patients and to be honest, are we not better than that?