Many new practitioners quickly realize that dentistry is more than just taking care of teeth.

The reality is that there is an ethical and moral dilemma for healthcare providers to consistently make decisions with their patients and/or for their patients that is in the best interest of their patients. It is truly ironic, considering that there is an assumption that a career path in healthcare would revolve around just that.

Maybe a more simple description of a healthcare provider is one who facilitates appropriate treatment for patients at a certain time, given the current circumstances with the current knowledge and data. Given the amount of thought and effort in obtaining in a career in healthcare, a safe assumption might be that all healthcare providers, by the time they begin to have patient contact, would expect nothing less than ethical patient-centered decision making from themselves and their colleagues.   

The lure of selling dentistry

Dental ethics

The undeniable need for intra-disciplinary (self-mandated), state and federal oversight in the healthcare profession is glaring proof that there must be some internal and external stressors challenging the decision-making process of healthcare providers. An argument can be made that what is lacking is a reliable system in their day-to-day work to help make ethical decisions, while simultaneously there is a flaw in the system that educates and trains healthcare providers, including but not limited to dentists. 

If we are educating and training dentists to provide quality care for their patients, one might argue that we can differentiate between clinical expertise (the quality of the finished dental restoration) and business quality. Although much of medicine has evolved into corporate group practices or very large private partnerships, the dental model is still very reminiscent of the “old school” style of healthcare. Most dental practices are still viewed as small businesses with 10 or fewer employees, run by one dentist as a private corporation or sole proprietor. The dentist then must also focus on practice management, for independent practice owners also serve as the CEO, CFO, COO, director of HR, and many other roles in the business. This can lead to a tough schedule of combining clinical responsibilities and practice management responsibilities. Many dentists are carrying large amounts of student debt, and with a tough schedule of clinical and practice management responsibilities, the dentist can quickly be lured into the selling of dentistry and not the practice of dentistry.

Yes, being an independent practice owner brings the freedom to grow the business as needed and when desired, both personally and professionally. The same freedom, however, brings moral, ethical, and business dilemmas that are new to most dentists early in their careers, having very little training in the business of dentistry. No matter how much we would like to believe that we all make the right choices and shun temptation, the truth is that we don’t and need some sort of oversight and/or guidance.

Healthcare ethics versus healthcare quality

In the Innovation Journal, Fox states that a central tenet of the Integrated Ethics model is that ethics is integral to quality. A healthcare provider who fails to meet established ethical standards is not delivering high quality healthcare. Conversely, a failure to meet minimum quality standards raises ethical concerns.  Thus, healthcare ethics and healthcare quality cannot be separated.1

Systems, specifically for internal monitoring of ethical decisions, should be in place, not only for the large practices or hospital-based groups that typically have them, but in the small practices as well. I would argue that these systems are equally as important in the small business setting, if not more. In the Journal of Ethical Decision Making in Healthcare Management, Peer notes that factors affecting managerial decisions in healthcare are situational and depend on the traits of the problem solver, his or her values and personal philosophy, the emotional nature of decisions, regulatory influences, institutional philosophy and mission, and resource allocation.2 Those variables are many, to say the least.

Considering ethics in dentistry

In the Journal of the American College of Dentists, Peltier questions if the above-mentioned decision making process is derived from the way that dentists generally see themselves or view their profession and its obligations, or if it’s a function of larger systematic and environmental forces, mostly outside of the control of individual practitioners. He notes that the basic delivery system in dental care is faulted.3 Most dentistry is delivered in a small office by a single autonomous provider to a single patient where the fundamental interests are perceived by some as intrinsically in conflict. The patient’s needs do not always conform to the dentist’s needs. For the dentist to behave truthfully, he or she must be able to exercise good judgment and occasional selflessness. This must be accomplished against the grain of what social psychologists call the “fundamental attribution error,” the notion that we place too much blame on character when research demonstrates that the environment is generally more powerful than individual will. Social psychologists can make even “nice” humans do nearly anything if you let them arrange the environmental contingencies accordingly.3 

Fox uses an iceberg as an example. She suggests that at the surface of the ethics iceberg lie easily observable decisions and actions as well as the events that flow from them in the everyday practices of an organization and its staff.1 In a small dental office, the “department heads” or managers and those within the department can routinely be the same person. The oversight or checks and balances can be minimal. 

Fox says that beneath that, organizational systems and processes drive decision-making. These organizational factors are not readily visible in themselves, but they become apparent when one looks for them, for example, by examining patterns and trends. Again, in a small office with meetings and rules that are often completely overlooked or even frowned upon, trends may go unnoticed until there is a critical breaking point. I have seen what is specifically noted in a resource guide for a healthcare board of directors, which is the submission of claims for reimbursement in reckless disregard or deliberate ignorance of the truth, as well as intentional fraud.4 I have seen fraudulent billing schemes identified by insurance companies, patients and honest colleagues. 

What should we do?

Deeper still lie the organization‘s ethical environment and culture, Fox continues, which powerfully, but almost imperceptibly, shape its overall ethics practices. This deepest level consists of values, understandings, assumptions, habits and unspoken messages – what people in the organization know but rarely make explicit. This level is critically important because it is the foundation for everything else. Yet because this level can only be revealed through deliberate and careful exploration, it is often overlooked.1 How different would the environment be if every healthcare business was mandated either federally or by the states to have continuing education and documentation of policy and regular reviews of its ethical environment and culture, systems and processes, decisions and actions? 

Ethical considerations for dentists

In the book “Leading Corporate Citizenship,” Waddock says that foundation values in the spheres of human civilization and natural environment are economic, government, civil society and environment.5 If acknowledging and addressing these values were mandatory and Waddock’s systematic approach was followed, under the government category would be respect for system integrity, transparency and the rule of law. Waddock suggests that we not only ask, “What can we do?” but also, “What should we do?” If we incorporate values-based management practices in systems approaches to the management of dental practices, as stated above, the temptation of wrong-doing and hopefully the poor decisions that lead to wrong-doing would lessen significantly.

One way to do this is by aligning ourselves with a proven CE organization that can teach us how to practice dentistry at a higher level in a predictable manner. The benefits that a systematic process and philosophy offers clinicians are numerous. Facially Generated Treatment Planning (FGTP), for example, is the backbone of the Spear curriculum. It can help practitioners achieve a sense of predictability on the clinical side, increasing their confidence and competence. This will in turn resonate throughout the practice, creating an environment in which the dentist and his or staff are working with the patient to identify appropriate steps toward health. This is very different from feeling the need and pressure to sell dentistry. 

(Like this article? Click this link for more articles by Dr. Kevin Kwiecien.)

Kevin Kwiecien, D.M.D., M.S., Spear Faculty and Contributing Author


  1. Fox,E.The Innovation Journal: The Public Sector Innovation Journal, Vol. 15(2), article 8.
  2. Peer, K., Rakich, J. Ethical Decision Making in Healthcare Management, Vol 77, no.4 Fall 1999
  3. Peltier, B. Some Observations on Truth Claims in a Profession, Journal of the American College f Dentists, Vol 71, No.2, 2004
  5. Waddock,S. Leading Corporate Citizenship