Dentistry as an Essential Public Good: Siege Ethics in the COVID-19 Pandemic

The column is a collaboration between AGD and the American College of Dentists. 

I am a dentist, but I am also a patient. I am an optimist, but I am also a historian. 

Just as the world wars shattered the 20th century’s innocence, COVID-19 has made us realize in the 21st century just how fragile the ground under us actually is. 

In 1941, Leningrad (present-day St. Petersburg) experienced a two-year siege by German forces. Resources became scarce quickly. The flash of steel in people’s mouths reminded Leningraders that dental offices had run out of amalgam early in the siege. Sincerity gave way to survivalist behaviors that preyed upon and exploited the vulnerable. Even the simplest acts of kindness, such as giving out food, were rare and seen as “the pure light of immaculate compassion.”¹ 

The siege reminds us of how survival mode can swiftly challenge and change the character of a society. Likewise, the current pandemic has thrown a number of dilemmas at us. Who would have dreamt that today’s dentists would have to think about furloughing their staff? Who would have thought that a dental cleaning would require the personal protective equipment (PPE) wardrobe of an infectious disease lab? Who would have imagined a world where, after the open-door policy of the HIV era, we would close the door to a COVID-19 patient? The world is still full of surprises. 

In April, 45% of dental offices had stopped paying all staff.² Based on American Dental Association data from the week of April 6, approximately 82% of dentists across the nation kept their doors open during the quarantine period despite the challenges. Of that number, 79% were closed to regular patients but open to emergency patients.³ For those who closed completely, fear of the unknown and unpreparedness for higher levels of PPE are likely reasons. 

To fuel efforts to acquire N95 masks and other PPE, dentists advanced the argument to governors that they too are essential emergency healthcare providers. Dentists are certainly on the front lines and will continue to be. To our patients who have stumbled into our chairs with pain, dentistry saves lives. 

We are uniquely positioned to counter pain by both compassionately diagnosing and effectively treating patients. We know that when patients go to the emergency department with dental pain, it only leads to more anxiety, delayed treatment-planning and adverse outcomes. Preventing that situation is our job. 

Ethics During COVID-19 

Though we usually understand ethics only as a synonym for rules, its Greek root, “ethos,” means character. During this pandemic, our ethos has been revealed. Some of us may have found ourselves at home not knowing what to do. Some of us are trying to just keep the basic gears of our practices moving. Some of us are trying to keep people employed, while some of us are trying to stay employed. Regardless of our situations, we must remember that our staff and our patients supported us during the best of times. We must be there for them in difficult times. 

According to the American College of Dentists’ handbook on ethics, the “chief motive [of a dentist is] to benefit mankind, with the dentist’s financial rewards secondary.”⁴ In other words, the mandate is to serve others above oneself. Most Americans do not receive regular dental care. In fact, on average, only 40% of the U.S. population saw a dentist last year.⁵ During the pandemic, we can only imagine how that percentage has shrunk. The time for us to address this staggering statistic is now, despite any personal difficulties. 

In the past, times of crisis have rejuvenated the American imagination. The generations before us worked hard to craft new solutions during the Great Depression and World War II, times in which the public good became the greatest good, and society mobilized for that purpose. Ordinary dentists expanded access to care by making it easier for their communities to pay. For example, the previous dentist at my brother’s practice accepted chickens as payment for dental care during the Great Depression. In Washington, the Unemployed Citizens League helped to organize a bartering network so that people with various skills, including dentistry, could trade their services for others.⁶ During the Great Recession of the early 2000s, bartering was similarly on the rise in healthcare.⁷ 

Bartering ethics raises the question of whether the exchange is in the best interest of both parties. As Drs. Peltier and Jenson point out in their primer on dental ethics, “Bartering relationships … are legal (when income is posted as revenue on tax forms) but can result in patient exploitation.”⁷ Exploitation, bordering on indentured servitude, is definitely possible in such an arrangement. As the authors point out, “How does a person who generally works for $30 per hour barter with someone who charges $3,000 for a root canal and crown on one tooth? The dental treatment is equivalent to 100 hours of patient labor.”⁸ Dentists who go this route will undoubtedly have to exercise their judgment wisely when making determinations. 

Rising commercialization also requires us to reflect on our ethics. Up until the 1960s, courts regularly upheld the professional integrity of dentistry, meaning that the decisions of the dental board were seen as final and authoritative. But, starting in the 1970s, antitrust laws were applied for the first time to the medical and dental professions. These professions came to be seen by courts as “market participants,” treating them as businesses instead of professionals with their own jurisdictions. 

When profit-making — whether by a parent corporation that has to report to shareholders or by a new dentist treating patients while unconsciously driven by student debt — becomes the dentist’s sole aspiration, not only does the care and concern that promote meaningful values fade, but the very tenets of care and concern lose their meanings. The profit-making motive can be so potent that it can dilute an act of charity by turning one’s focus to public image-making. 

In times like these, we should focus on presenting dentistry as an essential service for the public good rather than as a business. Although we might think only of our free work as pro bono dentistry, we are actually offering pro bono service every day, as pro bono is short for the Latin “pro bono publico,” for the public good. The work we do as dentists goes beyond fee-for-service. We might all agree on this foundation of service, but where we differ may be in determining just how much to serve. Ultimately, each of us is left to reflect upon this individually. But, together, we can reflect on our purpose, which we must be very clear about. Awareness and honesty are critical. Ethics has a lot to do with self-realization. Self-realization has everything to do with purpose, and purpose shapes what we as dentists end up doing in the world — from which patients we accept to how we treat them. What informs the choices we make? How are our choices made? Understanding our responsibilities determines the nature and magnitude of our responsiveness. 

Becoming aware of our intentions is critical in any sphere of life, but especially so when it involves irreversible treatment upon a fellow human being. Does debt impact our ability to treat? Our ability to choose treatment plans? The dental professional must be vigilant and closely attuned to the origins of its motivation. 

Imparting Ethics 

As a first step toward reflecting on our intentions, we can think of how we describe our professional pursuits. The language of entrepreneurship has overtaken the language of professionalism. The French root of “entrepreneur” means “to undertake.” We have become accustomed to using the term entrepreneurship to describe success when undertaking a business risk — primarily of the individual. But we must ask, “At what cost?” It is the language of the words “healing” and “healthcare” that instead promote the patient. 

Our current language of professional ethics and values is one that students and practitioners may subscribe to in order to pass classes and state examinations, but it is not the language most of us learned growing up. While it teaches professionals-in-training a set of principles, it less reliably motivates an individual’s ethical decision-making in the moment. 

Newer graduates with more debt than ever before and newer practice owners are under tremendous financial pressure. As they individually face enormous personal choices within dental practice, they need more than cultural competence, good practice management and clinical mastery. They need to be able to make sound in-the-moment decisions if they find themselves between the blurry lines of responsibility and authority that unfortunately are common in today’s dental employment landscape, where ownership stakes by dental management companies and private equity firms make change and feedback more challenging. 

We live in an era of customization, from the contents of a Chipotle burrito to the workouts suggested by our smartphone app. But ethics, the most personal of choices, is still taught without regard for the individual. Without sufficient multidisciplinary ethical training, we remain merely proficient technicians of the oral cavity. For example, narratives bring ethics to the fore. This is because “narratives can show us the many gray areas between good and evil,” as well as teach us how to be responsive “not in due time but in time.”⁹ Ethics is self-identity. We must reflect and anchor ourselves deeply in our professional values in order to move all of us forward. 

Empowered with a refined sense of purpose, we can better assess how to use the tools at our disposal, such as telehealth modalities, to make them pro bono and serve the public good. Maybe if we try hard enough, we can use virtual tools to reclaim the virtue of service. 

Although “siege ethics” exposes a dark potential within us all, even in the worst of times, such as during the siege of Leningrad, “the charitable urge proved … indestructible.” There were “hundreds of people who sought out orphans or took a glass of hot water to a helpless neighbor.”¹ 

Amid furloughs and bankruptcies, I pray all of us can be these charitable-minded people. We are dentists, and we are essential. 

Na’eel Cajee, DMD, MTS, a practicing endodontist, holds a master’s in theological studies focusing on ethics and history from Harvard Divinity School. To comment on this article, email impact@agd.org. 

References 
1. Yarov, Sergey. Leningrad 1941–42: Morality in a City Under Siege. Cambridge, Polity, 18 Sept. 2017. 
2. Bannow, Tara. “Healthcare Loses 1.4 Million Jobs in April as Unemployment Rate Hits 14.7%.” Modern Healthcare, 8 May 2020, modernhealthcare.com/finance/healthcare-loses-14-million-jobs-april-unemployment-rate-hits-147. Accessed 17 Sept. 2020. 
3. Nasseh, Kamyar, and Marko Vujicic.“Modeling the Impact of COVID-19 on U.S. Dental Spending.” American Dental Association, Health Policy Institute, April 2020. 
4. American College of Dentists. Ethics Handbook for Dentists: An Introduction to Ethics, Professionalism, and Ethical Decision Making. 2016. 
5. “Dental Care Utilization in the U.S.” American Dental Association, Health Policy Institute, ada.org/~/media/ADA/Science%20and%20Research/HPI/Files/HPIgraphic_1117_2.pdf?la=en. Accessed 10 Sept. 2020. 
6. Gregory, James. “The Great Depression in Washington State: Economics & Poverty.” University of Washington, depts.washington.edu/depress/economics_poverty.shtml. Accessed 10 Sept. 2020. 
7. Sharpe, Rochelle. “Recession Drives More People to Barter For Health Care.” Kaiser Health News, 17 June 2009, khn.org/news/barter/. Accessed 10 Sept. 2020. 
8. Peltier, Bruce, and Larry Jenson. Dental Ethics Primer, 3 Jan. 2018, acd.org/wp-content/uploads/Dental-Ethics-Primer-2017_Peltier-and-Jensen.pdf. Accessed 10 Sept. 2020. 
9. Hallie, Philip. Lest Innocent Blood Be Shed: The Story of the Village of Le Chambon and How Goodness Happened There. Harper Perennial, 8 April 1994.