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Journal of the

American Collegeof Dentists

New Voices in Dental Ethics

Fall 2013Volume 80Number 3

A publication advancing excellence, ethics, professionalism,and leadership in dentistry

The Journal of the American College ofDentists (ISSN 0002-7979) is publishedquarterly by the American College ofDentists, Inc., 839J Quince OrchardBoulevard, Gaithersburg, MD 20878-1614.Periodicals postage paid at Gaithersburg,MD. Copyright 2013 by the AmericanCollege of Dentists.

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For bibliographic references, the Journalis abbreviated J Am Col Dent and should be followed by the year, volume, numberand page. The reference for this issue is:J Am Col Dent 2013; 80 (3): 1-40.

Journal of the

American Collegeof Dentists

Communication Policy

It is the communication policy of the American College of Dentists to identifyand place before the Fellows, the profession, and other parties of interest thoseissues that affect dentistry and oral health. The goal is to stimulate this community

to remain informed, inquire actively, and participate in the formation of public policy and personal leadership to advance the purpose and objectives of the College. The College is not a political organization and does not intentionally promote specificviews at the expense of others. The positions and opinions expressed in College publications do not necessarily represent those of the American College of Dentists or its Fellows.

Objectives of the American College of Dentists

T HE AMERICAN COLLEGE OF DENTISTS, in order to promote the highest ideals in health care, advance the standards and efficiency of dentistry, develop goodhuman relations and understanding, and extend the benefits of dental health

to the greatest number, declares and adopts the following principles and ideals as ways and means for the attainment of these goals.

A. To urge the extension and improvement of measures for the control and prevention of oral disorders;

B. To encourage qualified persons to consider a career in dentistry so that dentalhealth services will be available to all, and to urge broad preparation for such a career at all educational levels;

C. To encourage graduate studies and continuing educational efforts by dentists and auxiliaries;

D. To encourage, stimulate, and promote research;E. To improve the public understanding and appreciation of oral health service and its importance to the optimum health of the patient;

F. To encourage the free exchange of ideas and experiences in the interest of betterservice to the patient;

G. To cooperate with other groups for the advancement of interprofessional relationships in the interest of the public;

H. To make visible to professional persons the extent of their responsibilities to the community as well as to the field of health service and to urge the acceptanceof them;

I. To encourage individuals to further these objectives, and to recognize meritoriousachievements and the potential for contributions to dental science, art, education,literature, human relations, or other areas which contribute to human welfare—by conferring Fellowship in the College on those persons properly selected for such honor.

EditorDavid W. Chambers, EdM, MBA, [email protected]

Managing EditorStephen A. Ralls, DDS, EdD, MSD

Editorial BoardLaura Bishop, PhDSusan Bishop, DDSHerb Borsuk, DDSMarcia Boyd, DDSKerry Carney, DDSAllan Formicola, DDS, MSRichard Galeone, DDS William Leffler, DDS, JDMichael Meru, DDSPeter Meyerhof, PhD, DDSKirk Norbo, DDSMartha S. PhillipsAlvin Rosenblum, DDSH. Clifton Simmons, DDSPhilip E. Smith, DMDJim Willey, DDS

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Correspondence relating to the Journal should be addressed to: Managing EditorJournal of the American College of Dentists839J Quince Orchard BoulevardGaithersburg, MD 20878-1614

Letters from readers concerning any materialappearing in this journal are welcome [email protected]. They should be no longer than 500 words and will not be considered after other letters have already been published on the same topic. The editorreserves the right to refer submitted letters to the editorial board for review.

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OfficersW. Scott Waugh, PresidentKenneth L. Kalkwarf, President-electJerome B. Miller, Vice PresidentBert W. Oettmeier, Jr., TreasurerPatricia L Blanton, Past President

RegentsThomas J. Connolly, Regency 1Thomas A. Howley, Jr., Regency 2Geraldine M. Ferris, Regency 3Richard F. Stilwill, Regency 4Joseph F. Hagenbrch, Regency 5Carl L. Sebelius, Jr., Regency 6Steven D. Chan, Regency 7Rickland G. Asai, Regency 8

Linda C. Niessen, At LargeRonald L. Tankersley, At LargeRichard C. Vinci, At LargeStephen K. Young, At Large

Lawrence P. Garetto, ASDE LiaisonBrooke Loftis Elmore, Regent Intern

New Voices in Dental Ethics4 Writing off Copayments

Roberto Amato

9 Domestic Violence Dilemma in the Dental ClinicSapna Lohiya, DDS

12 Culturally Diverse Patients and Professionalism in DentistryAthena deBrouwer

18 College Students Practice Dentistry in Third-World CountriesLisa P. Deem, DMD, JD, FACD

Issues in Dental Ethics21 Ethical Considerations of Randomized Control Trials with Human

Participants in Dentistry: A Reflective AnalysisEric Chen

Departments2 From the Editor

Moral Incontinence

29 LeadershipThinking in a Straight Line

Cover photograph: “Can you hear me?”

©2013 Stockphoto.com/Antonio Diaz. All rights reserved.

My table partner at our school’sOmicron Kappa Upsilon dinnerwas an urbane stepfather of

one our outstanding grads. We chattedabout his start-up computer company. I eventually worked my interest in ethicsinto the conversation. My acquaintanceperked up immediately and asked what I thought about Dr. Harrington. “Dr.Who?” I mumbled. “You know that dentist in Oklahoma who infected all hispatients for years with dirty equipment.”He obviously knew more about this thanI did, although we do not know yet thefull extent of Dr. Harrison’s conspicuousbreaches of sanitary conditions.

Then the tough question: “You’re anethics professor. Tell me, if Harringtonhad wanted to, could he have stoppedhimself from practicing in an irresponsi-ble way that put so many patients atrisk? I know he knew he was doingsomething wrong. Is there such a thingas failure of will power?”

I had never thought of that either.But I knew right away what the answeris. I quickly ruled out ignorance, greed,and a perverse negative attitude towardhumankind. Multiple years of carelessmistakes did not sound right either. The dentist in question probably did notneed to be taught ethics. He was justmorally weak.

The technical term for this is inconti-nence. Unfortunately today, the term isused most often in connection with notbeing able to keep one’s hands at homeor bad bladder control. The full meaning

of incontinence is inability to manageurges one knows are inappropriate. Itseems to be a common affliction amongpoliticians these days. Smokers, over-eaters, and some folks in the financialindustry suffer from it.

The general view in ethics is thatknowing what to do is sufficient. At least that is where our responsibility forothers is too often thought to end. Oureducational programs in ethics, our editorials, and our aspirational codes of conduct seem to work from thisassumption. It would be so easy if all weneeded to do to fix the problem was toname it. There has been a small army ofacademics hard at work on the namingproject for several centuries.

Incontinence, in its many forms, isactually very common. Oscar Wilde anda few others get credit for the quote:“The only thing I can’t resist is tempta-tion.” If I had any way to collect on this,I would wager that every reader hasacted in a manner they knew was notquite right—today. Not big ones and notso as to be likely to be caught, but some-thing here and something there wewould like to take back if we were actingon our better natures. So we were goinga bit over the speed limit, and if therehad been an accident and the full factscame to light, we could be looking atmanslaughter. But nothing happened.Yes, we left the grandchild in the bath-tub while we stepped out for just a

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2013 Volume 80, Number 3


From the Editor

Moral Incontinence

Conscience is nothingmore than the voices ofthose we respect beinginternalized as a guide.

second to get the phone, but everythingwas fine. This is called moral luck. Andwe all count on it.

I asked my well-informed table companion what he thought aboutDeamonte Driver. Now it was his turn to say “Who?” I explained that a boy had died in the Washington, DC, areafrom a virulent sinus infection of oralorigin who might have been saved hadhe received timely treatment in either aprivate office or the safety net system.No response from my companion.

This started me to wondering.Deamonte Drive was a hot topic in thedental community for months. The oralsurgeon near Tulsa is not. In my sampleof one very savvy private citizen, theorder of interest was reversed. Whatmight be involved here? There have beenno named victims in the most recentcase. But perhaps there is more. In thecase of Deamonte Driver there was nobad guy—it was the system that failed. It is easier to rage against the system.Many in the oral health community evenused this as an opportunity to advocatefor more resources. We are much slowerto judge our colleagues.

Incontinence is a feature of humannature, and one that seems to be resistantto education. Enforcement drives itunderground. Yet it is obvious that itcannot be overcome by sheer will power.After all, that is what incontinence is—lack of will power.

The answer comes in recognizingthat, individually, we are pretty muchhopeless victims of incontinence. It doesno good whatsoever to wag our fingers

at others and say they should have tried harder. Okay, it does some good—it makes us feel morally superior. Theantidote is to admit that morality is not a private matter. There is somethingmore than people just hearing aboutdoing the right thing. We have to helpeach other do it.

Moral failing always involves others.If Dr. Harrington had not allowedunsterile conditions that placed patientsat risk for infection (if he had just hadbad thoughts about it), he would stillhave his license and I would not be writing this editorial. Falling down onour professional responsibilities isalways a community matter that hasconsequences for others. Perhaps pro-tecting against incontinence is also aprofessional responsibility. We can helpour peers. Conscience is nothing morethan the voices of those we respect beinginternalized as a guide. Dr. Harringtonmight have welcomed some colleaguesspeaking out to build his conscience.

Combating moral incontinence is a public job. We must speak out and confront wrong when we see it. Failureto do so is also incontinence. Somebodyhad the courage to stop a dentist in thesuburbs of Tulsa before he exposed morepatients to unknown and unnecessarysevere health risks, but it appears it wasnot another dentist.

3

Journal of the American College of Dentists


The dentist in question

probably did not need to

be taught ethics. He was

just morally weak.

Roberto Amato

AbstractProfessions are accorded respect andautonomy by society in exchange for theirwillingness to enforce their own profes-sional standards. A case is discussedwhere an associate discovers that the principal dentist is routinely not collectingthe 20% copayment required by insurancecontracts. Analysis shows that this practiceis unethical, illegal, and unprofessional.Practical advice is offered for how such an issue should be addressed.

Regardless of personal feelings,society has a tendency to placelabels on individuals. One specific

label, which is often sought by many is a professional title. In a broad sense, a professional is one who has gained in-depth understanding and knowledgeof a particular topic that is unattainableto the masses. The level of comprehen-sion, that the professional has obtainedis verified by a governing body. Once thistitle is obtained, the public has a sensiblereason to believe that the professional is well trained in their designation andwill perform their duties for those whoseek their expertise with integrity andcompassion and in an ethical manner.Dr. Jos Welie, professor at the Center ofHealth Policy and Ethics at CreightonUniversity Medical Centre, Omaha,Nebraska, explains that the title of professional is ultimately granted by the public; therefore, each professionalmust exist to serve the public’s interest(Welie, 2004).

Based on this definition of profes-sionalism, dentists are potentiallydeserving of the professional status.Dentists are oral health doctors focusedon diagnosing, treating, and preventinga wide range of disorders of the oral-facial complex. Additionally, in order topractice in Canada, one must be licensedin full accordance with the regulations,thus proving merit of the dentist’s professional title. Within any profession,there are bound to be situations thatrequire ethical and moral reflection, and dentistry is no exception.

The Issue: Reporting InappropriateWriting Off of CopaymentsThroughout the course of one’s career itis reasonable to assume that ethical orprofessional dilemmas will arise. Whenan actual predicament arises, ethical orprofessional issues must be confronted.One particular prominent issue whichplagues dentistry involves the collectionof copayments.

For the purpose of this essay, the following issue will be examined: Arecent dental graduate becomes a newassociate at a dental practice. The finan-cial terms of the verbal agreement withthe principal dentist to provide the associate with 40% of the fees collectedfrom the patients. However, after manymonths the associate notices a paycheckwhich does not reflect the anticipatedamount. It is discovered that the office isnot collecting the 20% copayment androutinely writing off the balance. Thisessay will identify the professional, ethical, and legal issues involved for oralhealthcare providers from a Canadian

4


Writing off Copayments


Mr. Amato is a student at theSchulich School of Medicine & Dentistry, University ofWestern Ontario. This essaywas awarded the Ozar-Hasegawa Prize for studentethics writing in 2011. Readersmay wish to compare this perspective from a studentwith the views of three dentalethicists on the same casethat appeared in this journal in the second issue in 2011.

viewpoint and present a professionalsolution for the associate dentist.

Why Writing Off Copayments IsEthically Wrong

The Royal College of Dental Surgeons ofOntario (RCDSO) outlines core values anda code of ethics for all Ontario dentists tofollow (RCDSO, 2004). The major ethicaland professional issues involved in thisscenario are autonomy, beneficence,nonmaleficence, justice, and integrity.

The autonomy of the patient is being compromised since the front deskis regularly writing off copayments with-out making an honest attempt to collectthe remaining balance from insuredpatients. If patients are not being told topay their portion of the fees, they are not given an option to make their owndecision to pay or not to pay. It may bethat patients do not understand theirinsurance coverage and are being misledto believe that they are 100% covered for treatments.

When the copayment is not collectedit saves the patient money and the prin-cipal dentist views this as an act ofbeneficence. He or she may justify thisaction as relieving some of the financialburden to patients. Therefore, they willremain content and return for furthertreatment. The beneficence to patients isquite large in this circumstance sincethey can always receive the best treatmentavailable without having to worry aboutthe financial burden of top-notch healthcare. However, the short-term benefit tothe patient is not without consequence.

Harm is being caused to other dentistsin the community, the associate, the

insurance company, and uninsuredpatients. Therefore, the principal dentistis displaying acts of maleficence.Additionally, by causing harm to thosegroups and individuals the principaldentist is responsible for the injusticeswhich are occurring. Other dentists inthe area, who follow the guidelines, maybe falsely portrayed by patients as selfishand “money hungry.” The associate inthis scenario is not being properly compensated. Unfortunately, without awritten agreement or a discussion ofpractice philosophies, misunderstandingssuch as these are likely to occur. Theharm to society may materialize down-stream with increased dental fees andhigher premiums resulting in dentalplans being overly costly for employers.Additionally, uninsured patients are presumably paying 100% of the dentalfees while the dentist only collects 80%from insured patients.

Ultimately, the principal dentist is exhibiting a lack of integrity. Thisbehavior is not trustworthy because itdeceives both the insurance companiesand the associate. Furthermore, he orshe is displaying lack of fairness towardsuninsured patients. One may make theclaim that it is not the primary intentionof the principal dentist to cause anyharm; yet, as a practicing dentist, it is hisor her responsibility to be aware of theimplications of such actions. In this particular scenario, there is no justifiableexcuse since the office is routinely writingoff copayments.

5



Other dentists in the area,

who follow the guidelines,

may be falsely portrayed by

patients as selfish and

“money hungry.”

Why Writing Off Copayments Is Legally Wrong

Although the principal dentist is behaving in an unprofessional manner,causing an injustice to others, he or sheis also legally liable for the actions. InOntario, according to the Dentistry Act,1991, under the RHPA (Regulated HealthProfessions Act), this is professional mis-conduct (RCDSO, 2005). The failure ofthe principal dentist to attempt to collectthe copayment from the patient violatesSection 2, Paragraph 34 of the DentistryAct, 1991, and as such, the dentist is subject to investigation and possiblelegal action. Under this act, “the feecharged is to be the fee that the dentistexpects to collect.” Hence, the legal obligation of the dentist is to inform theinsurance company that he or she iswilling to accept 80% of the fee as fullpayment for those specific procedures.

It is evident there is no reasonableattempt to collect the copayment.Therefore, in addition to professionalmisconduct, the dentist is also committinginsurance fraud. When a dentist commitsan act of this nature he or she is subjectto disciplinary action by the RCDSOwhich may include complete loss or temporary suspension of dental registra-tion and legal action by the insurancecompanies for committing insurancefraud (Ontario Dental Association, 2010).

Additionally, the associate is legallyrequired to report the principal dentistfor professional misconduct as outlinedin the RHPA Dentistry Act of 1991 (RCDSO,2004). Therefore, the associate may besubject to similar disciplinary actions asthe principal dentist for being aware ofthis misconduct and not following themandatory regulations.

Why Writing Off Copayments Is Unprofessional

The RCDSO recognizes that society hasgranted a certain level of trust to all dentists. Therefore, the RCDSO hasdevised a code of 15 ethical principleswhich hold Ontario dentists to a profes-sional level of ethical conduct. In thisparticular scenario, the principal dentistis in major violation of codes 2 and 6 and minor violation of code 11. • Code 2: Be truthful, obey the law,

and provide care with respect forhuman rights and dignity and without discrimination.

• Code 6: Provide unbiased explanationof options with associated risks andcosts, and obtain consent before proceeding with investigations ortreatment.

• Code 11: Accept responsibility for the care provided by authorized dental personnel.Code 2 clearly states “obey the law.”

By routinely writing off the copayment,the principal dentist is in direct violationof the Dentistry Act of 1991 as previouslyexplained. This is professional miscon-duct and insurance fraud. The RCDSOcan subject the dentist to disciplinaryaction and the insurance company canpursue legal action since the dentist misrepresented the full amount whichhe or she intended to collect. Also, Code6 is being broken since the dentist is notproviding an unbiased explanation ofthe true costs. Given that the dentist isnot collecting the copayment from certain patients, the true costs is only80% of what is claimed.

Code 11 requires the principal dentistto be fully aware of any acts of miscon-duct which take place in his or her office.Technically, it is not clear whether thefront desk is writing off the 20% copay-ment with or without the principaldentist’s knowledge. Nevertheless, accord-ing to Code 11, the principal dentist isstill liable for these actions.

The Obligation to ActWhen any dilemma or ethical situationarises, all members involved have achoice to make: to act or not to act.However, before jumping to any conclu-sions, a careful ethical analysis must firsttake place. A practical decision-makingtool for such ethical dilemmas is theUCLA Decision Making Model (Atchinson& Beemsterboer, 1991). The followingsteps are involved: (a) identify the ethicalproblem, (b) collect information, (c)state the options, (d) apply ethical principles to the options, (e) make thedecision, and (f) implement the decision.The main ethical dilemma involved isjustice versus beneficence. By not collect-ing the copayment, a great injustice isbeing suffered by many parties as previ-ously outlined, and this must be weighedagainst the beneficence to patients whoare not being fully billed. The associateought to be absolutely certain as to anywrong doings which are actually occur-ring. If the front desk is consistentlywriting off the 20% copayment, this mustbe verified prior to proceeding with any action. In the associate’s particularposition the fundamental choices are todo nothing, report the principal dentistto the RCDSO immediately, speak withthe principal dentist in a professionalmanner regarding this discovery, or anycombination of these actions.

One can reasonably assume that theassociate, as a recent graduate, has littlebusiness experience. It would be quiteeasy to not act on the informationrecently discovered and to turn a blindeye to the situation. This would avoidconflict with the principal dentist, alongwith possible legal hearings in whichthe associate may be called to testify. The risk of future tension in the dentalcommunity may be a problem the associate does not wish to experience.

6



According to the RHPA Act, 1991, thereare mandatory reporting guidelines inplace which require professionals toinform authorities when they have reasonable knowledge of a colleaguewho is displaying professional miscon-duct. By the letter of the law, in Ontario,the associate has 30 days to file a reportwith regard to the professional miscon-duct involving the principal dentist. TheProcedural Code ensures that no actioncan be taken against the associate for filing the report with honest intentions.Although this option of immediatelyreporting the principal dentist is follow-ing stringent adherence to the law, it isnot necessarily the best, primary option.Being part of the dental professioncomes with a sense of camaraderie;therefore, one must be fairly certain ofall of the facts before acting.

The approach I would follow, andrecommend for the associate, involvesan initial private discussion with theprincipal dentist. The principal dentistdeserves the respect of being spoken tobefore any further action is taken withregard to this particular scenario. Afterall, it may be possible that the principaldentist is unaware that the front desk isnormally not attempting to collect thecopayment. The best approach is to have a rational, calm, and informativediscussion with the principal dentist,explaining the professional implications,as well as the legality of the principaldentist’s actions, the downstream impli-cations to dental insurance, the cost topatients, and the associate’s wage. Theprincipal dentist has an obligation touphold the RCDSO code of ethics and follow the Dentistry Act of 1991 underthe RHPA. If the principal dentist is a reasonable person, he or she willunderstand the associate’s concern forjustice and realize the ramifications ofthese faulty actions. In the event that theprincipal dentist is unreceptive to theassociate’s concern the associate should

respectfully explain to the principal dentist that there is no choice but to filea report per the mandatory reportingrequirements of the RHPA Act of 1991.After careful analysis of the ethical issuesinvolved, the actions of the principaldentist are unfair to all parties involvedand outweigh the beneficence to selected patients.

The outcome of the associate’s deci-sion is dependent on the receptiveness of the principal dentist. Assuming theprincipal dentist is unreceptive to theassociate’s concerns and the report isfiled, the associate’s professional careershould not be in jeopardy. The associateis assured immunity upon filing a reportin good faith. Yet there still may be some consequences for this action. Theprincipal dentist may make life miserablefor the associate in hopes that he or shequits. Also, the principal dentist may makeknown the associate’s actions, whichmay deter other dentists from hiringthat associate in the future. Conversely, the associate may be lauded for theseactions by honest dentists as news travelsof the integrity and courage involved instanding up for justice. Sincere dentistswho have pure intentions want what isbest for their patients and the profession.Hence, future dentists should be proud ofthe associate for upholding the integrityof their profession since all patients,regardless of their oral health provider,have the right to be treated fairly. Theprincipal dentist, on the other hand, willmost likely not reciprocate this sentimentand may harbor uneasy feelings towardthe associate. It is fair to assume thattheir professional relationship may beforever tarnished. Additionally, there

7



According to the RHPA Act,

1991, there are mandatory

reporting guidelines in

place which require

professionals to inform

authorities when they have

reasonable knowledge of a

colleague who is displaying

professional misconduct.

may be some dentists who are disturbedby the fact that the associate reportedthe principal dentist; yet if they feel thisway, it is possible that they are guiltythemselves of committing similar acts.

The main driving force behind therationale to speak with the principal dentist and ultimately file a complaintstems from the Principle Approachaccording to O’Toole (2006). ThePrinciple Approach aims to reach a solution to benefit all parties involvedwhile simultaneously being fair or just.The associate has a duty to bring justiceto this situation since many are beingtreated unfairly, including uninsuredpatients, the insurance company, otherdentists, and the associate. The principaldentist is displaying a complete lack ofregard toward others simply by not collecting the copayment. Hence, it isunreasonable to expect these individualsto suffer simply because the principaldentist is writing off the copayment.Using the Principle Approach to con-vince others of a particular viewpoint isineffective against individuals who arenot concerned with the consequences oftheir actions. The principal dentist hasmost likely been writing off copaymentslong before the associate arrived. He orshe has yet to see any consequences ofthese actions and has most likely enjoyedsome of the benefits from the increasingpatient base. By primarily arguing fromthe viewpoint that it is “unjust” to behavein this manner, it may seem unthreaten-ing to the principal dentist. Therefore,the associate would have to emphasizethe downstream consequences, in theform of legal action, lower insurancecoverage for patients, and poor publicity,to get through to the principal dentist.

Ethical dilemmas can be overlookedwhen dentists do not follow a formaldecision-making process. However, if

one acts with honest intentions ofupholding the core values of the profes-sion then they ought to be deserving of the title “professional.” Being part ofany profession should be viewed as anhonour. Dentists have a social contractwith society to display certain core valueswhich should not be compromised.Approaching each moral dilemmathrough the UCLA Decision-MakingModel will aid one in making better decisions. The privilege and respectwhich comes with the title of dentist isone which must primarily be upheld bythose who follow the professional valuesthat define our profession. Althoughsome dentists may not see the harm inwriting off the copayments, it has beenmade evident, through a careful analysisof the professional ethics at play, thatserious unprofessional consequences are indeed probable. ■

ReferencesAtchinson, K., & Beemsterboer, P. (1991).UCLA Decision-Making Model (unpublished). O’Toole, B. (2006). Four ways we approachethics. Journal of Dental Education, 70(11), 1152-1158.Royal College of Dental Surgeons ofOntario (2004). Code of Ethics. Toronto: The College.Welie, D. J. (2004). Is dentistry a profession?Part 1. Professionalism defined. Journal ofthe Canadian Dental Association, 70 (8),529-532.

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In the event that the principal dentist is unreceptive to the associate’s concern the associate shouldrespectfully explain to the principal dentist that there is no choice but to file a report per the mandatory reporting requirements.

Sapna Lohiya, DDS

AbstractA case is presented where a dentist recognizes physical abuse of a patient.Although legally the dentist must reportsuch cases, the patient asks that this notbe done. Statistics are presented regardingthe prevalence and consequences of abuse,and one potential response is suggested.

Despite the heavy downpour ofrain, a true anomaly in the nor-mally sunny city of Los Angeles,

All Smiles Dental Clinic had opened itsdoors at the usual 9 a.m. hour. Dr. JanFreest had expected a slow morning—most of her appointments had beencancelled as many of her patients hadopted to stay indoors on such a stormyday. At 10:30 a.m., however, Dr. Freest’soffice staff informed her that an emer-gency patient has arrived. With hernewly cleared schedule, Dr. Freest askedher dental assistant to escort the patientinto the operatory while she reviews thepatient’s dental and medical history.

Mrs. Maria Alvarez is a 29-year-oldHispanic female with a history of spo-radic visits to the dentist. Her last visitwas 18 months ago when she was seenfor a fractured tooth. Dr. Freest’s notesindicate that the patient said she hadfallen down and that she also presentedwith bruises on her hands. Mrs. Alvarezwas pre-hypertensive.

After reviewing the chart, Dr. Freestenters the operatory and greets Mrs.Alvarez. Her elder brother, Mr. Santos,has accompanied her. Dr. Freest imme-diately notices several scars on thepatient’s face and bruising along herarms. After performing the extraoralexamination, Dr. Freest notes that thepatient has tenderness upon palpationaround her neck. The intraoral exami-nation indicates moderate mobility ontooth #8 and #9. Her lateral incisor andcanine (#10, 11) are both chipped. WhenDr. Freest asks Mrs. Alvarez about thenature of her injury, she responds: “I fell

down and hit my front teeth.” Dr. Freestis immediately suspicious of this response.Her patient’s injuries, in conjunctionwith the bruising, seem to suggest physi-cal abuse and not simply a fall. After Dr. Freest compiles the most appropriatetreatment plan for her patient’s dentalissues, she discusses her suspicions withMrs. Alvarez: “Your injuries are severeand do not seem to be merely caused bya fall. Could this possibly have beencaused by another reason, perhapsabuse?” Mrs. Alvarez remains quiet andinstead looks at her brother. Her eyesseem to yearn for support. After amoment, Mr. Santos tells his sister: “Goon, you can tell the doctor.” Mrs. Alvarezclears her throat and then explains in aquiet voice: “Yes, my husband is generallya very loving husband. Sometimes hegets mad though, and yesterday he hitme several times.” Dr. Freest knows that she is obligated to report this, butbefore she can tell them that, Mr. Santosinterrupts: “We know how this sounds,but please don’t tell anyone else. Ourelder sister reported her husband fordomestic violence and the governmentkept her safe for a little while. But afterhis time in jail, he found her and beat

9


Domestic Violence Dilemma in the Dental Clinic


Dr. Lohiya wrote this paperwhile a student at theUniversity of California, LosAngeles School of Dentistry. It is the 2011 winner of theOzar-Hasegawa prize for stu-dent ethics essays sponsoredby the American Society forDental Ethics.

her terribly. She became disabled andhad to flee to Mexico. Please, for Maria’ssake, don’t tell anyone. At least she hasme here. Our elder sister has no one inMexico.” Dr. Freest looks at Mrs. Alvarezand sees her patient’s eyes pleading withher to also turn a blind eye.

Dr. Freest has been challenged withan ethical dilemma. She must look outfor her patient’s overall safety and well-being. At the same time, she is legallyobligated to report cases of domestic violence. Should she risk losing herpatient’s trust and potentially put her in more danger by reporting this case?Or should Dr. Freest stay quiet and facethe legal repercussions and the certaintythat her patient will get hurt again?

ContextDomestic violence is defined by theNational Center for Victims of Crime asthe “willful intimidation, assault, battery,sexual assault, or other abusive behaviorperpetrated by one family member,household member, or intimate partneragainst another.” The staggering statis-tics associated with domestic violencemean that it is almost inevitable that weas health professionals will be faced with ethical dilemmas similar to thatconfronting Dr. Freest. In fact, researchershave found that one in every four womenwill experience domestic violence duringher lifetime. In the United States ofAmerica, a woman is beaten by an inti-mate or former partner every 15 seconds.Women who leave their batterers are at a 75% greater risk of being killed by the batterer than those who stay.Furthermore, every year, domestic violence leads to 100,000 days of hospi-talizations, almost 30,000 emergencydepartment visits, and approximately40,000 visits to a health professional. For these reasons, the reality of domesticviolence must be acknowledged byhealth professionals. We must becomecognizant of its dynamics so that we canprovide the best care for our patients.

Although domestic violence shows nobias for gender, race, or socioeconomiclevel, victimized patients can often beidentified by their demeanor and physi-cal appearance. These patients may havefrequent injuries that they say have beencaused by “accidents.” In the case of Mrs.Alvarez, she attributed her injuries toaccidental falls until further questionedby Dr. Freest. These individuals also maywear long-sleeve shirts and pants in order to hide their bruises. They may bedepressed, withdrawn, or anxious whenthey come into the dental clinic. DuringDr. Freest’s encounter with Mrs. Alvarez,the patient was quiet; she required theextra support from her brother to revealthe true nature of her injuries. It isessential to recognize such signs of abusein all patients and to listen carefully forany clues they may reveal so that thesecases are not overlooked.

Once a victim has been identified,understanding the pattern of domesticviolence provides invaluable insight intothe victim’s plight. These behaviors have often been referred to as the cycleof violence: abuse⟶guilt⟶excuses⟶honeymoon ⟶fantasy and planning⟶set-up⟶abuse. The abuse phase refersto the violent incident that leads tophysical and dental injuries. This is whenhealth professionals, family members,and friends first get involved and urgethe victim to seek help. This phase, how-ever, is quickly followed by abuser guiltand excuses, where he is worried hemay get caught; he therefore rationalizeshis behavior by blaming the victim. Thevictim experiences self-doubt and beginsto believe her abuser. The honeymoonphase starts next and is characterized bythe abuser attempting to keep the victimin the relationship by showering herwith gifts and affection. The victim oftenbelieves that the abuser has changed forthe better and therefore rejects profes-

10



Women who leave theirbatterers are at a 75%greater risk of being killed by the batterer thanthose who stay.

sional help and intervention. The abuserthen plans for his next attack, and thecycle of abuse begins again. In Dr.Freest’s case, Mrs. Alvarez described herhusband as a loving partner. She mayfeel this way because of the honeymoonperiod that follows such periods ofabuse. As the cycle of violence dictates,however, another abusive incident willlikely occur in the future.

ResponseDr. Freest uses this information toresolve her dilemma. Dr. Freest knowsshe must act with great care to ensureher patient’s safety. She must expressconcern and offer help. Dr. Freest alsomust weigh the principles of autonomyand beneficence in determining how tobest proceed. Autonomy refers to Mrs.Alvarez’s right to make an informed decision about her situation. Beneficence,however, requires Dr. Freest to act in away that serves the best interest of herpatients and to ensure that they remainin good health. Per the ProfessionalEthical Decision Making Model describedby Ozar and Sokol (2002), Dr. Freestidentifies the alternatives and weighswhat is professionally at stake againstwhat else is ethically at stake. She thendetermines what ought to be done. SinceDr. Freest is inexperienced in handlingincidents of domestic violence, she real-izes that the National Domestic ViolenceHotline will be better equipped to dealwith complicated cases like that of Mrs.Alvarez. She expects that they mayrespond appropriately and take the precautions necessary to guarantee herpatient’s safety. Dr. Freest informs theHotline by calling 800-799-SAFE (8233).During the call, Dr. Freest explains Mrs.Alvarez’s concern for her personal safetybecause of her elder sister’s domesticviolence experience. After hanging upthe phone, Dr. Freest discusses her decision to report with Mrs. Alvarez andprovides her with resources to seek helpon her own. The patient understands

that she is now being protected and isultimately satisfied with her doctor’sdecision. Dr. Freest then proceeds withher treatment plan and provides the dental care needed to stabilize thepatient and restore aesthetics. Mrs. Alvarezthanks Dr. Freest and promises to makemore regular dental visits to her so thatboth her dental and overall health canbe monitored.

Dr. Freest’s ethical dilemma is onethat many dental professionals will face.In fact, dentists may be in a unique position to identify domestic abuse casesas victims often seek dental care beforetreatment by a physician. Researchersfound that 16.7% of women seekingmedical care for rape injuries, and 9.2%of women seeking care for domestic violence injuries visited their dentists. Itwas also determined that 68% of womenbattered by their partners suffer headand neck injuries (Love et al, 2001).Dentists may play an important role inrecognizing these wounds as potentialmarkers for domestic violence duringtheir intraoral and extraoral examina-tions. For these reasons, it is importantfor dental professionals to become moreeducated on this topic so that they canassess a situation like Dr. Freest’s and takeappropriate action. By getting involved,dental professionals can improve theirpatients’ emotional and physical health.As evidenced by the case of Dr. Freestand Mrs. Alvarez, this is truly invaluable.■

ReferencesOzar, D. T., & Sokol, D. J. (2002). Dentalethics at chairside: Professional principlesand practical applications. Washington,DC: Georgetown University Press.Love, C., Gerbert, B., Caspers, N.,Bronstone, A., Perry, D., & Bird, W. (2001).Dentists’ attitudes and behaviors regardingdomestic violence. Journal of AmericanDental Association 132 (1), 85-93.

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800-799-SAFE

Athena deBrouwer

AbstractA case is considered in which the father of an adult patient from another culturerequests that only limited care be providedhis daughter. Additional indicated treatmentwas declined. The patient appeared todefer to her father as a cultural norm.Various ethical principles and the conflictsamong them are considered in light of cultural competency.

The Case of the Unhappy Daughter

Acheerful 25-year-old womancomes to the dental clinic com-plaining of pain in her maxillary

left central incisor. This tooth presentswith a deep carious lesion, slight mobility,and swelling over the apex consistentwith a diagnosis of a necrotic pulp. Heroral hygiene is quite poor and other deepcarious lesions are visible on the otheranterior teeth. The dentist recommendsradiographs of the affected teeth and anexamination. The patient requests herfather come in, and they speak in a foreign language. After a brief conversa-tion in their own language, the fatherresponds to the dentist in English with“just take care of the tooth that is bother-ing her today. We don’t want any X-rays,but if you have to take a picture of thisone tooth so that you can extract it, then go ahead.” The daughter sits quietlyavoiding eye contact with both the dentistand father and she looks very unhappy(Donate-Bartfield & Lausten, 2002).

The Importance of CultureAccording to Fearon (2003) in theJournal of Economic Growth, Canadaand the United States rank first and fifthin the western world respectively for cultural diversity. Furthermore, the proportion of minority individuals inthese populations is expected to risethroughout the coming years (Formicolaet al, 2003). As a result, culturally

sensitive situations are common andhighly relevant to dental professionalspracticing in Canada and the UnitedStates. Therefore, as an example of a culturally sensitive case, The UnhappyDaughter is worthy of this essay’s critical examination of the ethicalresponsibilities and conflicts of the dentist in this case, given the status ofdentistry as a profession.

“Culture is the set of values, beliefs,and behaviors shared by a group of people and communicated from onegeneration to the next” (Olson et al, 2008,p. 271). This definition is a reminderthat culture has a strong impact on

ethical decision making; culture deter-mines the emphasis its members placeon specific values. The hierarchy of values becomes so embedded in the livesof a culture’s members that it comes toseem natural; the hierarchy of valuescomes to seem like an absolute truth,universal to all people (Bhikhu, 2000).As a result, unless a person has recog-nized the workings of his or her cultureon the hierarchy of values, interactingwith people from different cultures canbe problematic. In contrast, the culturallycompetent practitioner is aware of his orher cultural values and attitudes, resists

12


Culturally Diverse Patients and Professionalism in Dentistry


Ms. deBrouwer is a studentat the Schulich School ofMedicine and Dentistry inOntario Canada. This essay is the 2012 winner of the Ozar-Hasegawa student essaycompletion sponsored by the American Society forDental Ethics.

stereotyping, and allows patients to communicate their views.

Because dentistry is a profession, theethical aspects of The Unhappy Daughterand similar culturally diverse situationswarrant careful consideration. I seetruth in the assertion of Welie (2004a,2004b, 2011), Hilton and colleagues(2005), and others (Cruess & Cruess,2000; Chandratilake et al, 2010) that aprofession is created by the existence ofa social contract. As such, I agree withWelie’s resulting definition of a profes-sion as “a collective of expert serviceproviders who have jointly and publiclycommitted to always give priority to theexistential needs and interests of thepublic they serve above their own andwho in turn are trusted by the public todo so.” I therefore define professionalismas the values, actions, and goals thatdemonstrate commitment to serving the“existential needs” of the public, regard-less of the implications of this service tothe “expert service provider.” In this way,professionalism requires that dentists act ethically in all situations, upholdingthe ethical principles of beneficence,nonmaleficence, justice, and autonomy.

Some Basic Ethical PrinciplesThe ethical principle of autonomy,which requires dentists to respect thedecisions of each patient, must be care-fully considered in the case of TheUnhappy Daughter. This is becauseautonomy includes the “patient’s right toretain his or her own cultural orienta-tion in interchanges regarding dental

care” (Donate-Bartfield & Lausten,2002). As a result of this patient’s partic-ular cultural orientation, the implicationsof the principle of autonomy are alteredin this case. The patient is above the ageof majority (older than 18 years) andtherefore has full authority to enter intofinancial agreements, such as dental fee payment (Willes & Willes, 2006).However, autonomy must also be consid-ered in the sense that it is the daughter’schoice to have her father handle herdental care decisions. As such, in thiscase, the principle of autonomy requiresthe dentist to involve the patient’s fatherin the treatment process out of respectfor the patient’s culturally-based decision.

In order to act ethically, the dentistmust also display beneficence by provid-ing competent delivery of dental carewith due consideration to the needs,desires, and values of the patient.Competent performance of the treatmentthe father has authorized is one waythat beneficence is involved in this case.If a more comprehensive treatment plancould be agreed on for the patient,through approaches considered later inthis analysis, there is potential for evengreater beneficence.

Upholding justice, which entails fairtreatment of all patients, will requireparticular effort in the case of TheUnhappy Daughter. It would be unfair to

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The culturally competent

practitioner is aware of

his or her cultural values

and attitudes, resists

stereotyping, and allows

patients to communicate

their views.

allow cultural differences between thepatient and dentist to negatively affectthe quality of this patient’s treatment. Inorder to avoid this injustice, a thoroughlyconsidered, sensitive approach must beused, requiring cultural competence onthe part of the dentist.

Nonmaleficence involves avoidingharming the patient. In the case of The Unhappy Daughter, treating the central incisor with the necrotic pulpwill prevent harm to the patient byreducing risk of infection and othercomplications and relieving the patient’spain. Nonmaleficence is more uniquelyinvolved in this case through respect for her culture, which will prevent the dentist from harming the patientemotionally and psychologically.

When Principles CollideAlthough dentists must strive to respectbeneficence, justice, nonmaleficence,and autonomy, ethical dilemmas some-times preclude universal adherence. Anethical dilemma is a situation in whichcommitment to one of the core ethicalprinciples results in another of the prin-ciples being violated or compromised to a degree.

In the case of The UnhappyDaughter, an ethical dilemma existsbetween beneficence and autonomy. Thebest interests of patient care will not beserved (beneficence) if only the centralincisor is treated, but it is also necessaryto respect the autonomy of the patientby accepting her father’s decision.Therefore, unless the dentist can influ-ence the father’s decision, the patientwill experience either a lack of respectfor her autonomy or a compromisedlevel of beneficence.

Justice and nonmaleficence are alsoin conflict in this case. This patientdeserves as high a standard of care as allother patients (justice), but suggesting

that the patient go against her father’swishes would be an act of maleficenceon the part of the dentist through disrespect of the patient’s culture.

The social contract that creates aprofession not only calls on dentists toact ethically (i.e., to pursue beneficence,justice, and respect for autonomy) butalso allows dentists the privilege of self-governance. Self-governance of Ontario[Canada] dentists is achieved throughthe Royal College of Dental Surgeons ofOntario (RCDSO), which is charged bythe Regulated Health Professions Act(RHPA), the Health Professions ProceduralCode, and the Dentistry Act of 1991 withthe responsibility of protecting the public.The RCDSO has created a Code of Ethics,which provides more specific guidanceto the dentists of Ontario than the ethical principles discussed above. Theprinciples of this code are helpful in thecase of The Unhappy Daughter and areenforceable by law. Violations of theseprinciples may be reported to theInquires, Complaints and Review Boardor the Health Professions Appeal Boardand later the Discipline Committee, ifnecessary. If the Discipline Committeefinds that a dentist has violated one ormore principles of the RCDSO Code ofEthics during patient treatment, thecommittee has the authority to revoke a dentist’s right to practice in Ontario,impose limitations on the dentist’s certificate of registration, reprimand thedentist, or require the dentist to pay afine to the government of Ontario.

Principle 1 of the code states that“the paramount responsibility of thedentist is to the health and well-being ofthe patients.” Involvement of Principle 1was established above, during discussionof the role of beneficence in this case.

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It would be unfair to allow cultural differencesbetween the patient and dentist to negativelyaffect the quality of thispatient’s treatment.

Similarly, adherence to Principle 15 was covered in the above discussion ofautonomy, which established that, inthis case, autonomy includes respect ofthe patient’s wish to include her fatherin her treatment decisions. Principle 15of the RCDSO Code of Ethics asserts dentists’ duty to protect the confidentialityof the personal and health informationof patients.” Clearly, the patient wouldneed to give the dentist permission toinclude her father in discussions of herdental care.

Principle 2 is particularly helpful for the present case and entreats dentiststo be truthful, obey the law, and providecare with respect for human rights and dignity without discrimination.Therefore, according to the RCDSO, it is the duty of the dentist in the case ofThe Unhappy Daughter to be mindful ofthe cultural orientation of the patientand to provide treatment of the higheststandard, regardless of cultural differ-ences between the dentist and patient.To fail to do so would be an act of dis-crimination. However, the dentist mustalso be aware of the facts of diverse cultures approach life with a different set of expectations, values, and interpre-tations and that their approach can beas satisfying and as rich to them as anyother culture is to any other person.Therefore, the highest standard of treatment for a given patient is a func-tion of that patient’s culture, amongother factors, and should be individuallytailored as such.

The RCDSO’s Code of Ethics Principle6 requires that dentists provide unbiasedexplanations of options with associatedrisks and costs and obtain consentbefore proceeding with investigations ortreatment. This principle has a uniquemeaning in the case of The UnhappyDaughter where it is imperative that the information required to generateinformed consent is given to the fatheras well as the patient, given the father’s

role in deciding which treatment hisdaughter will consent to. In a similarway, Principle 12 can only be achievedby conscientious consideration of thepatient’s cultural orientation, as it statesthat dentists should only provide com-promised or unconventional treatmentwith full disclosure or consent frompatients. Since the patient has placedauthority with her father, the full disclo-sure process should include the patient’sfather if the compromised treatmentthey have requested is to be justified.

Options for Managing the CaseIn the situation of The UnhappyDaughter, the dentist involved has fouroptions. The dentist could respond bydoing nothing, refusing to treat thepatient and sending the daughter andfather to another dentist. Acting in thisway would violate the professional valuesthat underlie the ethical principles discussed above, especially those of compassion and integrity, which call the dentist to help this patient, despitethe complexity of her case.

The dentist could also respond bydoing exactly as the father has requestedand treat the painful tooth but do nothingfurther. This response would demon-strate a broken commitment to informedconsent: it violates RCDSO CodePrinciple 12, pertaining to disclosureand consent for compromised treatment.In this case, informed consent has nottruly occurred, because the decisionmaker (the father) has not been fullyinformed. In addition, even though thefather’s unique role in consent has beenaccepted (out of respect for autonomy),it should be noted that the patient hasnot yet communicated her agreementwith her father’s treatment decision.Consent has not been given, and further

communication is required before anytreatment is performed.

A third possibility is to ignore thefather and discuss the patient’s conditionand treatment plan with the patientonly. However, this would be a form ofdiscrimination, violating RCDSO CodePrinciple 2 by failing to respect thepatient’s cultural orientation. Thisapproach also disregards the patient’sautonomy, which requires that the den-tist strive to create what Ozar and Sokol(1994, p. 126) refer to “as interactive arelationship with the patient as possible,”which cannot be achieved by forcing herto adopt an interaction model involvingthe patient and dentist only.

The dentist’s final option is to takethe patient’s culture into account and(with the patient’s permission) addressadvice to both the patient and her fatherin recognition of the evident importanceof paternal authority in their culture.The dentist would review all relevantinformation, including the options of the patient, associated consequences ofeach option, and probability of each consequence with the father. Withreceipt of this information, the fatherwould be capable of making an informeddecision about his daughter’s care.

I would select this final approach inthe situation of The Unhappy Daughter.I find this course of action ethicallypreferable because it ensures that thedaughter’s rights to consent and autono-my (cultural orientation) are respectedand that the cultural values of the father

15



and the daughter are incorporated intothe information process to achieve trulyinformed consent. It is hoped thatinforming the father will lead to a treat-ment plan that more fully addresses thepatient’s issues, which would constitutejustice by achieving a standard of treat-ment that is as high as possible for thepatient. Furthermore, this approachcould optimally lead to family supportfor improved patient oral hygiene practices in the future and therefore prevent harm to the patient (achievingnonmaleficence).

To further improve this course ofaction, the role of intercultural commu-nication should be taken into account,since “information-based communica-tions [which are used by dentists in theprocess of informed consent] are effec-tive when they present strong evidenceor compelling arguments that there willbe positive consequences associated withaccepting the recommendations in themessage,” but often, “people of differentcultures find different evidence or argu-ments compelling” (Olson et al, 2008, p.270). Therefore, the dentist in the caseof The Unhappy Daughter should takeinto account the fact that cultural differ-ences could render the treatment planexplanation less effective, decreasing thelikelihood that the patient will consentto the treatment and thereby limitingthe beneficence achieved by the dentist.Therefore, the dentist in this case shouldattempt to use culturally relevant lan-

guage and treatment options in order toimprove both the quality of informedconsent given by the father and the levelof compliance of the patient.

Intercultural communication is onecomponent of cultural competency, alarger skill set essential in culturally sensitive patient-dentist interactions. Infact, as Donate-Bartfield & Lusten note“a number of studies have suggested thatif health professionals are interculturallycompetent and skilled in recognizingand working with patient/client valuesand beliefs, the client response isenhanced” (2002, p 1007). Cultural competence can be developed by dentiststhrough one or several of the followingstrategies, which include, “(a) self-awareness through introspection, (b)[acquisition of] knowledge of the healthbeliefs and practices of cultures mostlikely to be served, (c) taking courses inintercultural communication, (d) learninga second language, (e) [acknowledging]patient’s interpretation of condition,[and] (f) presenting direct advice in afamiliar manner” (Galvis, 1995, p. 1103).By interacting with people of many cultural backgrounds, future dentists can become aware of the preferences,practices, and values of cultures thatthey were not born into (O’Toole,2006).This will give the dental studentsome idea of appropriate and effectiveways to interact with people of these cultures once they begin practicing dentistry. Exposure to diverse culturescan be acquired through travelling toforeign countries, volunteering in com-munity outreach programs, and eventhrough friendships with classmates. Inmy class at Schulich, we have membersof many different cultural groups, making socialization with classmatesnot only recreational, but an educationalopportunity. It should also not be for-gotten that classmates will remainimportant members of a practicing

dentist’s life and can be an importantway for dentists to discuss culturally andnonculturally based ethical dilemmas.Furthermore, classmates that share aculture with a given dentist’s patientmay be able to offer valuable advice onthe most sensitive and appropriateapproach for caring for that patient.

The ethical analysis above was performed using the principle approach,which is the approach most commonlyused in dental ethics. O’Toole defines a principle as, “a general normative standard of conduct, holding that a particular decision or action is true orright or good for all people in all timesand all places” (2006, p. 1153). Althoughthose that employ the principle approachfor all situations can be perceived asintractable, I believe it is an especiallyuseful in culturally sensitive situations,where the ethical action may be particu-larly unintuitive due to the bias createdby the practitioner’s own culture. Inthese cases, principles give the dentistfirm guidelines that can be used confi-dently because they are uninfluenced byculture. The relative importance placedon each of these principles should beadjusted according to the individualpatient, however, especially in casesinvolving cultural diversity.

In conclusion, a social contract existsbetween dentists and patients, bequeath-ing dentists the trust of the public,binding dentists to the service of theirpatient and society, and qualifying dentistry as a profession. As a result of this contract, dentists are called toanalyze culturally sensitive situationslike The Unhappy Daughter, in order toidentify and work through the ethicaldilemmas such cases can contain. Theethical principles of beneficence, justice,

16



nonmaleficence and respect for autono-my can guide dentists through theseethical dilemmas. Codes of ethics developed by dental associations andregulators like the RCDSO can also behelpful. In the case of The UnhappyDaughter, both the core ethical princi-ples and the RCDSO Code of Ethicsindicate that cultural competence andcommunication are important skills forethically navigating culturally diversepatient-dentist interactions. ■

ReferencesBhikhu, P. (2000). Rethinking multicultural-ism. London: Macmillan.Chandratilake, M., McAleer, S., Gibson, J.,& Roff, S. (2010). Medical professionalism:What does the public think? ClinicalMedicine, 10 (4), 364-369.Cruess, S. R., & Cruess, R. L. (2000).Professionalism: A contract between medicine and society. Canadian MedicalAssociation Journal, 162 (5), 668-669.Donate-Bartfield, E., & Lausten, L. (2002).Why practice culturally sensitive care?Integrating ethics and behavioral science.Journal of Dental Education, 66 (9), 1007-1011.Fearon, J. D. (2003). Ethnic and culturaldiversity by country. Journal of EconomicGrowth, 8 (2), 195-222.Formicola, A. J., Stavisky, J., & Lewy, R.(2003). Cultural competency: Dentistry and medicine learning from one another.Journal of Dental Education, 67 (8), 869-875.Galvis, D. L. M. (1995). Clinical contexts for diversity and intercultural competence.Journal of Dental Education, 59 (12), 1103-1106.

Hilton, S. R., & Slotnick, H. B. (2005). Proto-professionalism: How professionalizationoccurs across the continuum of medicaleducation. Medical Education , 39 (1), 58-65.Olson, J. M., Breckler, S., & Wiggins, E.(2008). Social psychology alive. Toronto:Nelson.O’Toole, B. (2006). Four ways we approachethics. Journal of Dental Education, 70(11), 1152-1158.Ozar, D. T., & Sokol, D. J. (1994). Dentalethics at chairside: Professional principlesand practical applications. St. Louis:Mosby-Year Book.Welie, J. V. (2004a). Is dentistry a profes-sion? Part 1. Professionalism defined.Journal of the Canadian DentalAssociation, 70 (8), 529-532.Welie, J. V. (2004b). Is dentistry a profes-sion? Part 2. The hallmarks ofprofessionalism. Journal of the CanadianDental Association, 70 (9), 599-602.Welie, J.V. (2011). Social contract theory asa foundation of the social responsibility ofhealth professionals. Medicine, HealthCare and Philosophy, 15 (3), 347-355.Willes, J. A., & Willes H. H. (2006).Contemporary Canadian business law:Principles and cases (8th ed.). New York,NY: McGraw-Hill.

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An ethical dilemma is

a situation in which

commitment to one of the

core ethical principles

results in another of the

principles being violated or

compromised to a degree.

Lisa P. Deem, DMD, JD, FACD

AbstractIncreasingly, applicants to dentalschools are reporting experiencesproviding dental care on third-worldmission trips. Perhaps they do notknow that this behavior is unethicaland illegal, but those directing andsponsoring these programs could notso easily claim to be unaware thatwhat they are doing is wrong. Policystatements and informational cam-paigns by professional organizationsmay help curb this abuse.

International dental mission trips areincreasingly popular among collegestudents aspiring to become dentists.

In an attempt to demonstrate the desireto attend dental school and a commit-ment to community service, increasingnumbers of college students are partici-pating in international outreach efforts.Unfortunately, the level of participationextends to the actual practice of den-tistry. Applicants are so unaware of theethical and professional obligations topatients that they proudly disclose theiractivities on dental school applications.“By the second week, I had successfullyadministered an inferior alveolar blockand extracted my first tooth on a boynamed Jonathan.”

Jonathan is an orphan in Costa Rica.Jonathan’s “oral surgeon” is a collegestudent on a dental outreach mission.Stunning activities like this are occur-ring throughout some internationaloutreach efforts, advertised specificallyto predental students. The dental teamexperience for predental students, asadvertised on one Web site, includes“dental exams, teeth cleaning, extrac-tions, and fillings.” College students areadministering anesthesia, performingextractions, placing sealants, preparingteeth, and otherwise practicing dentistryin all capacities on the world’s most vulnerable populations.

As an admissions officer at one ofthe largest dental schools in the country,I have the opportunity to read too many personal statements detailing

the escapades of college students that are frightening: “Utilizing my elevator, I loosened the periodontal ligamentaround #12 and after lightning-fast minutes, I held a premolar in my handthat represents the culmination and validation of years of anticipation, perse-verance, and sacrifice.” Whose sacrifice?

The activities described above aredisturbing on several levels. In anattempt to address the disparities inhealth care in third-world countries,activities such as these actually definedisparate treatment of people fromunderserved, impoverished nations.Supervising dentists and eager studentsequally share in the responsibility oftreating patients from third-world coun-tries in a way that would not only beinconceivable in developed countries,but illegal. The scenarios describedshould give all of us pause.

The dentists who accompany studentson the outreach trips facilitate and ultimately condone the behavior byteaching technical procedures and allowing care to be rendered. Whilethose dentists may contend they are

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College Students Practice Dentistry in Third-World Countries


Dr. Deem is associate professor of dental publichealth and associate dean for admissions, diversity, andstudent services at TempleUniversity Kornberg School of Dentistry and a member ofthe Pennsylvania State Boardof Dentistry. This featureappeared in the May/June2011 issue of the PennsylvaniaDental Journal and was thewinner of the 2012 AmericanCollege of Dentists–AmericanAssociation of Dental EditorsJournalism Prize.

doing “good,” potentially they may bedoing harm. Extraction of teeth byuntrained personal has been practicedfor centuries. However, in this centurywe understand the potential complica-tions and long-term harm that couldresult from this practice. The students,our future healthcare providers, demon-strate questionable ethics, poor decisionmaking, and a lack of understanding ofthe profession. They are working undera misguided ethical and professionalunderstanding of the field of health care.They presume that any care is betterthan no care. In many cases, no care isindeed better than harmful care. Theorphans and others who line up formiles in pain, waiting in sweltering heat in underdeveloped countries fordesperately needed health care wait forcompetent, experienced “foreign” orAmerican dentists. They may not beinformed that they are being used toprovide experience for a college studentwho intends to apply to dental school tobecome a dentist. They are not given achoice. It is our duty to ensure that allpeople are treated with the same profes-sionalism, compassion, and standards of care as the most prominent patient in the wealthiest country.

International humanitarian out-reach activities are an excellent way forthe most fortunate to give back to theunderserved. Dentists who participate in outreach efforts in risky, oftenuncomfortable, situations should becommended for their beneficence.However, some dentists are willing to

disregard their ethical obligations topatients and the practical aspects ofimproper training, as soon as they crossthe borders. Dentists must recognize the value of a dental education and take no part in enabling the practice ofdentistry without one. Undervaluing the requirement of a dental education inthe profession in the name of access tocare has become increasingly common.Procedures that have been historicallywithin the sole domain of highly educated, well trained dentists are beingdelegated to other, less qualified oralhealthcare team members in an attemptto address the needs of the underserved.It appears that the slippery slope continues all the way to college studentspracticing dentistry on orphans in third-world countries because treatmentdelivered below the standard of caremust be better than no care at all.

In order to solve the increasing problem of college students practicingdentistry in undeveloped countries during dental missions, we must firsteducate the dentists who are supervisingthe practice. While those dentists facili-tating the unacceptable practice ofden tistry are in the minority, those who allow the behavior exist in largeenough numbers that many applicantsfrom across the U.S. report practicingdentistry during dental missions ontheir dental school applications.

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College students are

administering anesthesia,

performing extractions,

placing sealants, preparing

teeth, and otherwise

practicing dentistry in all

capacities on the world’s

most vulnerable populations.

For most dentists it is self-evident thatshowing a college student how to per-form extractions and super vising theactivity are problematic. For those whodo not have a personal or professionalproblem with the concept, organizeddentistry could take the lead by remind-ing dentists who participate in dentaloutreach of their ethical obligations totheir patients whether at home orabroad. Similarly, the American Collegeof Dentists could post a policy statementon the issue, which reflects its mission ofadvancing excellence, ethics, profession-alism, and leadership in dentistry.

Additionally, continuing educationclasses on ethics and professionalismcould include the issue as a componentin the course. Finally, state boards ofdentistry should notify licensees that delegating duties to a person that isknown not to be competent is consideredunprofessional conduct and disciplinaryaction can be taken against the license.

The high value that dental schoolsplace on commu nity service in consider-ing applications may be, in part, thecause of college students stretching theirservice to include the actual practice ofdentistry. Applicants think that interna-tional outreach activities serve them as being demonstrative of both theiraltruism, as well as their newly acquireddental skills. However, some schools are rejecting otherwise academically

qualified applicants based on the questionable ethical integrity and self-serving behavior of outreach participants.

College students must be informed of the unacceptable act of practicingdentistry without training. The studentsmust be educated in the ethical principlesof the profession. This can be accom-plished through a policy statementpublished by the American Associationof Dental Education, which is activelydiscussing the topic. Additionally, theNational Association of Pre-HealthAdvisors has been notified of the activi-ties of their stu dents and has reachedout to dental school admissions officersfor advice.

Addressing access to care issues, minimizing health care disparities andserving the poor are missions that weshould adopt personally as health careprofessionals. As dentists, we have richopportunities to give back to society,both locally and globally. We assume aposition of trust in the communities weserve within our borders and beyond. It is our responsibility to ensure that thetrust we enjoy from of all members ofsociety, especially those from the mostvulnerable populations, is not misplaced.■

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The dentists who accompany students on the outreach trips facilitate and ultimatelycondone the behavior by teaching technical procedures and allowingcare to be rendered.

Eric Chen

AbstractA potential conflict is built into the roles of dentists and researchers with regard toethical principles such as beneficence,nonmaleficence, respect for autonomy, andjustice. The practitioner has an obligationto do what is believed to be best for theindividual patient: the dentist as researcherhas an obligation to use rigorous experi-mental methods, including randomizedcontrol trials (RCTs) to discover what isbest for patients generally, including theinvestigation of experimental modalities.This is the equipoise problem—how can a professional be assured of offering themost beneficial treatment available if onlyusing approaches that have worked in the past? This essay explores the ethicalfoundations for this challenge and proposesa groundwork for balancing ethical obligations to patients and the needs forscientific and public health advances.

In 2006, clinicians from the Division of Oral and Maxillofacial Surgery atthe University of Texas Southwestern

Medical Center asked a common questionof the dental and medical professions:What can we do to ensure the besthealth outcome for our patients?Specifically, these clinicians wanted toknow if the administration of postopera-tive antibiotics would be beneficial inreducing infection in patients with openmandibular fractures. They conducted a prospective randomized trial to inves-tigate the effectiveness of—and thusnecessity for—postoperative antibioticregimens in the treatment of 181 patientswho presented with open mandibularfractures (Miles et al, 2006).

Ethical Considerations of Randomized ControlTrials with Human Participants in Dentistry

A Reflective Analysis

Issues in DentalEthicsAmerican Society for Dental Ethics

EditorBruce Peltier, PhD, MBA

Editorial BoardAnika Ball, MA, RDHMuriel J. Bebeau, PhDPhyllis L. Beemsterboer, RDH, EdDJessica De Bord, DDS, MSD, MARonald W. Botto, PhDEric K. Curtis, DDS, MALawrence P. Garetto, PhDPeter M. Greco, DMDLarry Jenson, DDS, MAAnne Koerber, DDS, PhDMarilyn S. Lantz, DMD, PhDDonald Patthoff, Jr., DDSAlvin Rosenblum, DDSToni Roucka, DDS, MAGerald Winslow, PhDPamela Zarkowski, JD, MPH

Correspondence relating to Issues inDental Ethics should be addressed to: Bruce Peltier [email protected]

While all of the patients received preop-erative antibiotics and intraoperativeantibiotics on the day of surgery, theywere randomly placed into two groupsto determine whether or not they wouldreceive postoperative antibiotics. Withinthe eight-week follow-up period, eightinfections occurred in the group thatreceived postoperative antibiotics, and 14infections were found in the group thatdid not receive postoperative antibiotics.Despite this disparity, statistical analysisyielded no statistically significant differ-ence. Therefore, the clinicians concluded,based on their study that no statisticallysignificant benefit was found in theadministration of postoperative antibi-otics in their patients with mandibularfractures (Miles et al, 2006).

A baby born today will live a longerlife on average than any other humanbeing in history (Centers for DiseaseControl and Prevention, 1999; Caspari &Lee, 2004). Thanks to advancements inbiotechnology, improvements in publichealth, and substantial gains from drugtesting in human patients, humanhealth is better than it has ever beenbefore. Despite the fact that we have yetto find cures for a host of diseases, andthat the final years of life are plagued by

21


Issues in Dental Ethics

Mr. Chen is a student in theClass of 2016 at the UCLASchool of Dentistry. This essaywas the 2013 winner of theOzar-Hasegawa Prize awardedby the American Society forDental Ethics.

diseases that diminish quality of life,some argue that any obligation to discover cures for these conditions mustnot include potential harm to humansubjects in research trials. Especially forplacebo-controlled randomized controltrials (RCTs), observers question the ethical permissibility of using humanparticipants if a novel treatment mightbe statistically ineffective.

Indisputably, human experimenta-tion involves important and ultimatequestions about personal dignity and the inviolability of persons. What differ-entiates human experimentation fromin vitro drug testing is that artificial substitutes designed specifically for the purpose of the experiment are nolonger used; rather, we are using humanbeings, and this fact alone makes RCTsfar more complex and unnerving.Animal research has similar limits.While it is true that other organisms canserve as proficient substitutes for humanresearch, there are innate biological differences between Homo sapiens andDrosophila melanogaster and evenbetween humans and our closest pri-mate relatives. To assess the true efficacyof a drug regimen designed for Homosapiens, it seems clear that human sub-jects must, at some point, be used forabsolute validation of medical research.

This paper will explore various ethical and moral views related to theconduct of randomized control trialswith human subjects in dentistry, gener-ating a dialogue of increasingly complexarguments in favor of in vitro humanresearch. An assumption of this paper isthat primary inviolability (that life can-

not be violated) and sanctity of life needno justification whatsoever. However,this philosophical principle does notcontribute to the discussion of RCTs withhuman subjects in that it categoricallydismisses RCTs as morally unjustifiableand is thus not useful in the present dis-cussion (Merritt, 2005). Therefore, inorder to justify the infringement of pri-mary inviolability—to justify the usage ofhuman beings as research subjects withsubsequent potential harm or evendeath from treatment—certain valuesmust be asserted that exceed the valuesthreatened by RCTs. This paper strives tosubstantiate the notion that randomizedcontrol trials with human participantsin dentistry and oral medicine for thepurpose of clinical research and theadvancement of human health is ethicallyand morally permissible.

The ResearcherBy definition, clinical research is medicalresearch conducted with human subjectsto ascertain, for example, the efficacy ofnovel medications and treatments. Theinvestigator’s goal is to scientifically andempirically establish the best treatment.But the main issue here concerning clinical trials is that the only way for theinvestigator to conduct a fruitful study is to have some of the subjects bear medical burdens or risks that are notreasonably expected to bring direct benefit to them (Merritt, 2005).

For instance, in a 2009 randomizedplacebo-controlled study at the Depart-ment of Thoracic/Head and NeckMedical Oncology at the University ofTexas Anderson Cancer Center,researchers randomly assigned patientswith high-risk oral premalignant lesionsto receive a high dose of green teaextract, a low dose of green tea extract,or a placebo (Tsao et al, 2009). With epidemiologic data supporting thenotion of oral cancer prevention bymeans of green tea extract through thereduction of the angiogenic stimulus,

tumor stromal vascular endothelialgrowth factor A, the study’s methodologyrequired that the placebo group patientsreceive the equivalent of no formal medical treatment. Consequently, theplacebo-controlled patients were notexpected to receive the purported benefitof oral cancer prevention, and thus theybore a medical burden. Ultimately, thestudy did not yield statistically signifi-cant differences between patient cohortsthat received a high dose of green teaextract and those that received the placebo. However, the study did show adose-response effect when higheramounts of green tea extract wereadministered. Resultant oral cancer prevention thus supported future long-term clinical testing of green tea extractin patients with high-risk oral prema-lignant lesions (Tsao et al, 2009).

As seen in this example, it is impera-tive in a clinical trial that researchersadhere to the strict methodological pro-cedures of research with professionalintegrity to validate the study and to justify human participation. Otherwise,to allow human subjects to participate ina poorly executed trial lacking sufficientstatistical strength is to expose people tomedical burdens and risks without therealistic hope of adding any valuableinformation to the established knowledgebase (Merritt, 2005). Thus, to completethe clinical trial to produce scientificallyvalid data and to share this new infor-mation with the dental communitybecomes an absolutely essential criterionin ensuring that subjects are not exposedto medical risks in vain. Just as promi-nently, the relationship between thepatient and the investigator is groundedby the shared understanding that thesubject voluntarily and willfully agreesto partake in the clinical study for thepurpose of aiding the scientist in thismedical investigation. Further, an

22



ultimate aim of the researcher is theprogress of dental medicine—and in this one example, the prospect of a common and affordable supplement inoral cancer prevention.

The Oral Healthcare ClinicianMoral considerations also come intoplay, and here we consider the oralhealthcare clinician, the healer. The clin-ician’s duty is to place the needs of thepatient above all and to protect thepatient’s health in the face of everythingelse, which may include protection fromresearch participation that involves thehardship of medical burdens or risks.This is an ethical and moral obligation,particularly for a trained dental profes-sional. With regard to dental medicine,clinicians are governed by the moralconsiderations of beneficence—improvinga patient’s condition—and nonmalefi-cence—removing or mitigating harmsuch as refraining from providing falsetreatments (Beauchamp & Childress,2001). These two principles, along withpatient autonomy, justice, and veracityin the form of truthfulness, establish thefundamental ideology that governs theprofessional ethics of dental medicine(American Dental Association, 2012).

However, the following is the innateconflict between the oral healthcare clinician and the researcher. From theclinician’s standpoint, the needs of thepatient override the fact that a patientmay indeed be a research subject. Fromthe researcher’s standpoint, however,the needs of the patient may not be theimmediate priority; instead, the point isthe testing of a novel treatment such asgreen tea extract against a placebo toprevent oral cancer for the advancementof scientific and clinical knowledge.Thus, the dichotomy between clinicianand researcher, between caregiver andscientist, between healer and investiga-tor is stark with regard to answering tothe needs of the patient. In the case ofRCTs, however, both obligations—that of

the clinician and that of the researcher—cannot be equally and concomitantly fulfilled. This raises the question: Whencan both obligations be fulfilled? Ormore specifically, when is an oral health-care clinician simultaneously allowed to be a researcher?

Practitioner EquipoiseTo first evaluate the role transformationfrom clinician to researcher within thecontext of human research, consider the broad case of practitioner equipoise,the balancing of essential factors. In agiven clinical scenario, it is true that adental clinician may not always knowthe best treatment. For instance, giventhe physical body of evidence and symptoms, the clinician may have noreason to choose one treatment overanother. Thus, the clinician is in a stateof equipoise. Given the evidence, proce-dure A seems neither significantly betternor worse than procedure B; therefore,the dentist may just as well flip a coin to select one procedure over the other. For example, a clinician may have noreason to favor the use of a conventionaldenture over an implant prosthesis in aparticular patient. Equivalently, withrespect to placebo RCTs where somepatients are randomized to receive notreatment and others are randomized to receive treatment, a clinician is inequipoise with regard to what will be ofgreater benefit to the patient. As a result,perhaps RCTs simply formalize andhighlight a dentist’s individual state ofequipoise by means of a clinical trial. Byeliminating selection bias in randomlycontrolling the trial, a dentist is inequipoise (uncertain if one procedure oragent is better than the other) and thusethically permitted to conduct RCTs.

There is an obvious flaw here whenwe consider everyday clinical situations.An individual dentist is often in a posi-

23



The relationship between the

patient and the investigator

is grounded by the shared

understanding that the

subject voluntarily and

willfully agrees to partake

in the clinical study for the

purpose of aiding the

scientist in this medical

investigation.

tion with sufficient evidence to deducewhich treatment is best suited for thepatient. Even if a dentist does not havesufficient evidence to be certain which isthe best treatment, the dentist at leasthas more evidence one way or another.Thus the delicate evidential balancing actrequired for equipoise rarely occurs inclinical practice. By this same reasoning,an oral healthcare clinician cannot justifyplacing patients in RCTs based solely onindividual practitioner equipoise.

Clinical Equipoise—DentalAmalgamNow take a step farther and examineclinical equipoise as opposed to individ-ual equipoise. If there is genuineuncertainty in the dental community asto whether one treatment is better thananother, then by definition the dentalcommunity is in clinical equipoise(Miller & Brody, 2003). Due to disagree-ment over the preferred treatment, the matter cannot be settled as oralhealthcare clinicians reach differing conclusions given the same body of evidence. In contrast to an individualdentist choosing between two proceduresbased upon practitioner equipoise, theentire profession is at clinical equipoise,which produces the need for RCTs.Dentists who first suspected amalgam asa potentially hazardous filling materialin comparison to resin composites weredutifully concerned about the potentialharm. As such, many RCTs groundedupon clinical equipoise were conductedacross the world resulting in controver-sial results. (Bellinger et al, 2006; Woodset al, 2007).

In 2006, researchers at HarvardMedical School conducted a randomized

clinical trial with 534 children betweenthe ages of six and ten to investigatepotential neuropsychological and renaleffects of amalgam restorations as compared to children who received composite restorations (Bellinger et al,2006). The study found no statisticallysignificant adverse neuropsychologicalor renal effects within the five-year fol-low-up period for those children withamalgam restorations. However, a differ-ent RCT with 507 children conductedover a seven-year follow-up period founda strong, positive correlation betweenmercury exposure from amalgamrestorations and urinary mercury excretion. The mean mercury urine concentrations of the amalgam cohortwas more than double the compositeresin cohort — 3.2 �g/L vs. 1.5 �g/L(Woods et al, 2007). In light of clinicalequipoise, genuine uncertainty in thedental industry (as shown by the greatnumber dental amalgam studies) is avalid argument for the use of RCTs toexplore this question.

As long as the treatments and testingprocedures satisfy the requirements of clinical equipoise, then clinician investigators are able to satisfy theirtherapeutic obligation to patients withinthe context of RCTs (Miller & Brody,2003). Here, RCTs are not only scientificexperiments designed to produce knowl-edge that can help enrich patient care,but also treatments administered by oral healthcare clinicians who preservefidelity to the ideology of beneficenceand nonmaleficence that govern theethics of dental medicine. This makes it ethically permissible for clinicianinvestigators to conduct RCTs withoutforfeiting therapeutic obligation byimparting treatment consistent with scientifically validated measures of care.Given genuine lack of consensus of preferred treatments (as seen in theprominent case of dental amalgam use)along with effective informed consent, itis ethically permissible for clinicians to

conduct RCTs with human participantsin institutional settings.

Arguments Against RandomlyControlled TrialsIt is important to acknowledge thegreater implications of RCTs with humanparticipation, as moral philosophy provides the basis of medical and dentalethics. Hans Jonas, the twentieth centuryGerman philosopher and pioneer in the field of bioethics, presented severalinteresting cases regarding why humansubjects should not be used for medicalresearch. One of his strongest argumentsis that “no complete abrogation of self-interest”—or in other words, sacrifice—can be found in the social contract, andthus human sacrifice towards the benefitof society can neither be obligatory nor morally justified (Jonas, 1969).Specifically, the theory of the social contract refers to seventeenth centurypolitical philosophical thought as pro-pounded by Thomas Hobbes’s Leviathanand John Locke’s Second Treatise ofGovernment. The citizens of society asdepicted by these authors consent torelinquish some of their rights to thegovernance of society in exchange forguarantee of enforcement of theirremaining freedoms (Harrison, 2002).

Jonas argues that the good of societyalone cannot justify the potential sacri-fice of the individual. However, Jonasagrees that at times the rights of theindividual can be trumped by the rightsof society, but only in cases of utmostemergency. Specifically, Jonas drawsupon the state of war when the needs ofsociety temporarily supersede individualcitizen’s right. Only in such an extremecase can society call upon its members to engage in combat and risk their lives(Jonas, 1969).

In RCTs, however, the cause formembers of society to engage in medical

24



research and risk their lives is a matterof improving and not rescuing society—dental advancement is not war. Jonaswould argue that it would not be the endof society, for instance, if a certain per-centage of oral cancer patients continueto die. Similarly, decreasing mortalityrates from a disease like oral cancer orincreasing quality of life through noveldirect restoration treatments of cariesbased on RCTs does not make it morallypermissible to use human beings asresearch subjects. “Progress,” Jonasclaims, “is an optional goal, not anunconditional commitment,” and thussacrifice by means of human participa-tion in RCTs goes above and beyondwhat should be asked of any humanbeing (Jonas, 1969).

ReflectionJonas’s use of the word “sacrifice” maybe too strong and even deceptive whenclaiming that RCTs with human subjectsare impermissible due to the absence ofcomplete abrogation of self-interest inour social contract with society. Whileno one, not even society, can ask othersto sacrifice themselves as a victim in thename of science, no one is a completevictim of medical research through RCTspurely for the public good. On the con-trary, there are potential and concretegains as postulated by the investigationof scientific inquiry and maintained bythe supervision and compassionate careof clinicians. Much more would be atstake if society were not allowed to conduct RCTs. In particular, there is nomore extreme risk to individuals volun-tarily participating in RCTs than if RCTswere never conducted in the first place.

Furthermore, Jonas is wrong to saythat medical research via the social contract would result in the completeabrogation of self-interest. Consider thefact that many individuals suffer fromoral cancer and subsequently experiencesignificantly decreased quality of life

or worse. According to a recent 2012 epidemiologic review of oral and pha-ryngeal cancers, there are approximately30,000 new cases of oral and pharyngealcancers diagnosed annually in theUnited States alone, with five-year survival rates as low as 27.6% for AfricanAmericans (Saman, 2012). It is thereforejustified to proceed with RCTs for contin-ued research for the countless patientssuffering from oral cancer.Subsequently, if the argument for contin-ued human research is not for overallgood, it can be argued strongly in favorof individual self-interest so as toincrease the quality and extent of life.

Clinician TrainingConsider the analogy of the duty toaccept the situation in which dentists-in-training treat patients that may reasonably be considered “experimentalsubjects.” It is in society’s interest (aswell as the self-interest of students) totrain dental clinicians. How else wouldperiodontal disease be treated or impactedthird molars extracted if there were notrained oral healthcare clinicians? It isalso true that dentists-in-training musttreat patients a first time. On what moral basis can someone insist thatsomeone else must accept treatmentfrom clinicians-in-training so that theythemselves can avoid it? Each of us bearsa shared responsibility to train future clinicians. If not, we bear a greater burden—that is, there will be no oralhealthcare clinicians to treat our oralhealth concerns.

25



Although we are all permitted

to decline personal treatment

from student dentists, we

ought to accept it. We do

so for reasons of self-interest

and societal benefit in the

continuation of the dental

professions.

Although we are all permitted to declinepersonal treatment from student den-tists, we ought to accept it. We do so for reasons of self-interest and societalbenefit in the continuation of the dentalprofessions. Thus, the grounds of self-preservation upon which to reject carefrom a clinician-in-training are similarto those upon which to reject participa-tion in a clinical trial for the sameself-preservation, which in this lightseems rather foolish. One of thestrongest arguments against RCTs withhuman subjects—that citizens have noobligation in the social contract to sub-ject themselves to research and endurepotential risks—is flawed. Opponentssuch as Hans Jonas argue that the goodof society cannot justify the harm of the individual. Human participation inmedical research is rather a matter offairness, as will be explained next.

Rawlsian Fair PlayIn the case of Rawlsian fair play, RCTsmust be examined in light of the certainsocietal obligations in relation toAmerican philosopher John Rawls’s veilof ignorance. Rawls’s best-known work,A Theory of Justice, popularized the veil of ignorance—an approach to investi-gating the morality of an institution oraction based upon the thought experi-ment of randomly redistributing societalroles without knowledge of the assignedrole (Rawls, 1999). Imagine that youcould have been born into any socialposition in life; rich or poor, talented or not, and of any ethnic group.Consequently, we can debate the way a particular issue will impact each member of society through the lens ofimpartiality. To begin, as citizens of theUnited States we have certain obligations

to social contracts. Dentists and studentsmust also abide by certain regulations asmembers of the professional community.We have consented to these obligationsimplicitly rather than explicitly. As members of these societies, if we eachreceive the fair share of benefits, thenfairness demands that we experience the fair share of burdens, as well.

In accordance with the veil of igno-rance, one might easily be born as anindividual with syndromic cleft lip andcleft palate or occlusal caries on toothnumber 19. We have all benefited fromexperienced clinicians in dentistry byvirtue of their educational experiencesin school. Someone else, also a memberof the society to which we each have tacitly consented, bore the burden totrain the clinicians from whom we benefit today. These instructors bore thisburden because someone before themshouldered the identical burden in train-ing a previous generation of clinicians.

Therefore, as free and uncoercedbeneficiaries of trained clinicians,respecting the principle of fairnessunder the veil of ignorance (where onemay or may not be in dire need of oralcare), the moral permissibility of subject-ing oneself to the same burden begins to take form. In fact, fairness in the form of justice, alongside autonomy,beneficence, nonmaleficence, and veracity constitute the dogma that governs dental medicine. Although theADA Code states that “the dentist has aduty to treat people fairly,” its corollary—that we should be expected to be treatedfairly ourselves—rings true in light ofaccepting clinicians-in-training underthe veil of ignorance.

With regard to human participationin RCTs, we are simultaneously consid-ered beneficiaries of clinical researchfrom other members of society who wereonce subjects and bore this previous bur-den. Bone graft procedures to establishdental implants and inferior alveolarnerve blocks in dental anesthesia, for26



As members of these societies, if we eachreceive the fair share ofbenefits, then fairnessdemands that we experience the fair shareof burdens, as well.

instance, are specific procedures arisingfrom clinical studies with human subjectsin dentistry and oral health (Esposito etal, 2006). As a matter of fairness in rela-tion to Rawls’s veil of ignorance, RCTswith human subjects for the purpose ofresearch in dentistry is in fact ethicallyand morally permissible.

Public HealthThe significance of population needsthrough public health is equally impor-tant as fairness examined through theveil of ignorance. Jonas’s claim thatprogress is an optional goal of societymay not be applicable in this light.Recall the dentists who first suspectedamalgam as a potentially hazardous fill-ing material and were concerned withthe public health implications of usingmercury in dental fillings. As a result,many RCTs were conducted across theworld resulting in controversial results,(Bellinger et al, 2006; Woods et al,2007). Although dentists today stillmaintain conflicting views on amalgamuse, it is important to recognize thatRCTs have been appropriately conductedto address worldwide dental publichealth concerns. RCTs must have suffi-cient statistical power to provide bothuseful and reliable knowledge for thedental community and enhance thegood of society via enhanced publichealth. Understandably, this knowledgemust be of valuable and meaningful concern such as the potential risks ofamalgam use, and be applied with duediligence towards prospective improve-ments not only for the advancement of the dental field, but also for the promotion of public health and safety.

From the greater public health standpoint, both the research and clinical communities have a prevailingresponsibility to safeguard the worldpopulation from threats to health andenhance quality of life. Our ethical obligation as dental professionals to

cultivate ample data regarding the effica-cy and safety of innovative treatmentsbefore they are made publicly availableis crucial, and this is where RCTs providethe best measure for ensuring suchprogress. As Franklin Miller of theDepartment of Bioethics at the NationalInstitutes of Health rightly argues, “It issocially irresponsible to hasten newpharmaceutical products to market orvalidate new medical or surgical proce-dures if a conservative burden of proofhas not been met and reasonable doubtspersist about their therapeutic merit”(Buchanan & Miller, 2006). Fortunately,and after myriad trials over decades ofresearch, the scientific burden of proofhas been met regarding the safe andeffective merit of dental amalgam in theUnited States.

Conclusion: JusticeUltimately, it is unjust to discount legitimate public health concerns whenconducting RCTs with human partici-pants in the study of novel treatmentsand procedures in dentistry. As previouslydiscussed in the case of dental amalgamand potential renal effects from mercuryexposure, and in the case of administer-ing green tea extract in oral cancerprevention, RCTs provide the most powerful methodology to assess thedevelopment of novel health interven-tions for patients’ self-interest and publichealth. Harkening back to the first RCTcase regarding the administration ofpostoperative antibiotics in patients withmandibular fractures, that particularstudy concerned not only the necessityof an additional round of antibiotics, butalso the implicit cost. It is imperativethat we, as dental professionals give dueconsideration to the greater ramificationsof research and vigorously invest in valu-

able, cost-effective dental interventionsthat exceed the scientific burden of proof.

If we briefly consider a society without randomized control trials, howwould its people benefit from—and learnto trust—novel treatments and procedures?Most importantly, how would such asociety be fair towards its people if nostrict methodology were used to determinethe efficacy and safety of innovativehealthcare interventions before makingthem publicly available? The publichealth concern is more of a matter ofjustice. This is ultimately a matter ofallocating resources and responsibilitiesfairly as examined through John Rawls’sveil of ignorance, particularly in meetingthe healthcare needs of the socially disadvantaged. It is justice that champions the development of viableinterventions and worthwhile solutionsto positively affect the health of theworld’s underprivileged.

Above all, as dental professionals, we bear the professional and clinicalresponsibility not only to honor ourpatients with respect to autonomy,beneficence, nonmaleficence, veracity,and justice, but also to provide them thebest empirically tested care possible. And it is by virtue of randomized controltrials with human participants that wecan provide our patients with the mostscientifically just, clinically sound, andethically fair methodology in the devel-opment of novel health interventions for their self-interest as well as for theinterest of population and public health.

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Empowered by the trust of our patientsand the societies in which we serve, we must—as dental professionals— honor the invaluable contributions ofour forebears, including that of researchsubjects, impart our patients with thebest standard of oral health care possible,and always uphold a sensitivity to theethical complexity of serving in ouresteemed yet humble profession. ■

ReferencesAmerican Dental Association. (2012).Ethical principles and code of professionalconduct. Chicago. IL: The Association.Beauchamp, T. L., & Childress, J. F. (2009).Principles of biomedical ethics. New York:Oxford University Press.Bellinger, D. C., Trachtenberg, F., Barregard,L., Tavares, M., Cernichiari, E., Daniel D., & McKilay, S. (2006). Neuropsychologicaland renal effects of dental amalgam inchildren: A randomized clinical trial. TheJournal of the American MedicalAssociation, 295 (15), 1775-1783.Buchanan, D. R., & Miller, F. G. (2006) Apublic health perspective on researchethics. Journal of Medical Ethics, 32 (12),729–733.Caspari, R., & Lee, S. H. (2004). Older agebecomes common late in human evolution.Proceedings of the National Academy ofSciences of the United States of America,101 (30), 10895-10890.Centers for Disease Control andPrevention. (1999). Ten great public healthachievements—United States, 1900-1999.Morbidity and Mortality Weekly Report, 48(12), 241-243.Esposito, M., Grusovin, M. G., Coulthard, P.,& Worthington, H.V. (2006). The efficacy of various bone augmentation proceduresfor dental implants: A Cochrane systematicreview of randomized controlled clinical trials. The International Journal of Oraland Maxillofacial Implants, 21 (5), 696-710.

Harrison, R. (2002). Hobbes, Locke, andconfusion’s masterpiece: An examinationof seventeenth century philosophy.Cambridge, UK: Cambridge University Press.Jonas, H. (1969). Philosophical reflectionson experimentation with human subjects.Daedalus, 90 (2), 219-247.Merritt, M. (2005). Moral conflict in clinicaltrials. Ethics, 115 (2), 306-330.Miles, B.A., Potter, J.K., & Ellis, E. (2006).The efficacy of postoperative antibioticregimens in the open treatment of mandi-bular fractures: A prospective randomizedtrial. Journal of Oral Maxillofacial Surgery,64 (4), 576-582.Miller, F. G., & Brody, H. (2003). A critiqueof clinical equipoise: Therapeutic miscon-ception in the ethics of clinical trials.Hastings Center Report, 33 (3), 19–28.Rawls, J. (1999). A theory of justice.Cambridge, MA: Belknap of HarvardUniversity Press.Saman, D. M. (2012). A review of the epidemiology of oral and pharyngeal carci-noma: update. Head and Neck Oncology, 4(1), 1-7.Tsao, A. S., Liu, D., Martin, J., Tang, X. M.,Lee, J. J., El-Naggar, A. K., et al (2009).Phase II randomized, placebo-controlledtrial of green tea extract in patients withhigh-risk oral premalignant lesions. CancerPrevention Research, 2 (11), 931-941.Woods, J. S., Martin, M. D., Leroux, B. G.,DeRouen, T. A., Leitao, J. G., Bernardo, M.F., et al (2007). The contribution of dentalamalgam to urinary mercury excretion inchildren. Environmental HealthPerspectives, 115 (10), 1527–1531.

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RCTs must have sufficientstatistical power to provide both useful andreliable knowledge for the dental community and enhance the good of society via enhancedpublic health.

David W. Chambers, EdM, MBA, PhD, FACD

AbstractRational human discourse is not as common as we imagine or as we wouldlike it to be. Sometimes it is necessary to use fallacies and fabrication to get to the point we favor. This essay is an illustrated list of 33 handy tools for avoiding thinking straight.

Iam an avid reader of editorials and letters to the editor. I also take notes inmeetings. I review papers in the fields

of dentistry, education, management,and philosophy. I watch the televisedbroadcasts of our city council and thewater board.

I am a student of public thinking.Generally what draws my attention isthe marvelous capacity of a group ofhumans to start from a common pointin fact and end, in a few deft steps, in afull symphony of divergent conclusions,many of them pretty wobbly. The mindworks in such wonderful and mysteriousways. Thinking straight is often not oneof them. From the famous “motivatedmisunderstanding”—“I don’t see whatyou are getting at”—to naked name-calling, we muddle it when given a reasonable chance.

There is an entire realm of secondaryconsiderations. “I was going to make thispoint, but since Wishywashy brought itup already, I need to go in a differentdirection or my contribution may not berecognized as ‘distinctive.’” “If I speaklast I will have a chance to look like I am contributing the piece that leads toaction.” “Well, I see that Flabbergast isgoing to argue for X. He’s a turkey, so Iwill start loading my gun to get him.”These are not flaws in reasoning. Theyare traits of human nature—and thereare many more—that predispose us tobent logic.

I sat down a few hours ago to makea short list of human slips in logic and

argumentation. This essay will mentionand illustrate the first 33 that poppedinto my mind. Except for the final one, the Fallacy Fallacy, they are listed in alphabetical order because they tend to be pressed into use randomly, or “as needed,” rather than in any structured fashion.

ad Hominem“You can’t believe everything you read in a supplement to JADA because they arefinancially supported by the companieswhose products are featured in the‘research’ reports.” “Who would believehim? He can’t even think in a straightline.” “It’s just another crazy idea frominside the Beltway.” “Chambers is apointy-headed intellectual. What wouldhe know about dentistry?”

The thrust of an ad hominemargument is at the person who is makingthe claim, not the merits of the claimitself. It is generally true that stupid people say stupid things, but the unsup-portable position, not the person, shouldbe the target of refutation. There is nological reason, for example, that a dental product that is touted by an expert who has a financial stake in the firmthat sells the produce is not in fact asuperior product.

In its kindest form, the ad hominemargument is a corrective to the argumentfrom authority that was common

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Leadership

through the dark ages and the middleages. Thinkers seldom looked behind anargument if it had a famous name on it.This is the origin of the misconceptionthat primum non nociri (first do noharm) is part of the Hippocratic Oath. It is not. As is obvious from the Latinphrase, this is a much later position(probably crafted by a lawyer for theplaintiff who wanted to give it a littleweight by attributing it to the Father of Medicine).

A more familiar term for adhominem argument is “name-calling.”Kids learn this technique early in life. In some cultures, notably the Chinese,name calling is a public admission of the weakness of one’s own argument. It translates “I know I have lost the argument, but I am just so angry.”

Adjectives as Arguments“Based on careful consideration of thebest evidence, some of the nation’s mostrespected experts at the prestigiousHokum Institute have prepared a fair-minded proposal that should please allrational patriots.” On the other hand, “It is rumored that some individuals of unknown background, allegedly connected with the so-called HumbugInstitute, are furtively circulating a hastily contrived and pretty scary set of‘unconventional’ ideas.” If we removethe adjectives from these two sentenceswhat we are left with is little more than:“We have two proposals: one from theHokum Institute and the other from theHumbug Institute.”

The more adjectives in a sentence,the less power it has. It is also annoying

when others offer us the results of theirthinking rather than the material theybegan with.

Affirming the Consequence“The best materials and careful tech-niques reliably lead to worthy results.The examples in the CE speaker’s slidesare truly outstanding clinical results.Therefore, the clinician is careful anduses good materials—and I could expectthe same.” “Unethical people give evasiveanswers and are afraid of transparency.She said she would rather not explainwhy she approached the matter the wayshe did. It begins to look like her motivescould be questionable.” “If it quacks likea duck…”

This one was a classic teachingdevice among the sophists—the precur-sors to lawyers in Aristotle’s time. It is aperversion of the very sound logical toolcalled modus ponens. If A then B. A,therefore B. That is good logic. If A thenB. B, therefore A is lousy logic. The rulemight prove the result, but the resultdoes not prove the rule. Like so many of the “thinkos” that follow, part of theprocess is sound: If A then B might beevidence-based from top to bottom. The conclusions of EBD can still be dangerously wrong, even when the evidence is ironclad.

Anchoring“I have heard of dental students who are $700,000 in debt for their education.What do you think the average studentdebt is?” “I don’t know the exact statisticson suicide among dentists, but it wouldn’tsurprise me to hear five or ten in a thousand, or more.” “We have been talking about how Americans are lesstrusting of their neighbors, or of profes-sionals, and especially of politicians.

Before we get into this mess, let me tellyou a personal story…” “I remembersomething that actually happened.”

Have you ever wondered why theguy selling refrigerators starts with thetop of the line or why executives of acompany associated with an industrialdisaster avoid guessing or guess low?They are attempting to “anchor” a number in your mind.

All humans are susceptible to thisanchoring bias. Its use is as ubiquitousas the Ginsu Knife salesman who namesa price and then systematically lowers itand piles on benefits so that the bargainis compelling even at twice what youmight have had in mind to begin with.In some experiments by Nobel Prize winner Daniel Kahneman, people weretold to write down the last two digits oftheir social security number and thenasked how many African nations thereare in the U.N. The guesses about coun-tries very closely tracked the randomnumber issued by the U.S. government.More men will opt for heart surgerywhen they know that it has a 90% success rate than if they are told thatthere is a one in ten chance of fatality.Anchoring depends very weakly onveracity—an anchor value can be a longway from the truth and exert a powerfulpull. What matters most is that theanchor is concrete. Saying that the debtincurred in purchasing or establishing a dental practice is “pretty high” will be limp. Suggestions that it might be as much as a million dollars (or even stating the irrelevant fact that corporatejets for oil executives might range as highas $4 million) will move the needle.

Argument from Ignorance“There is no conclusive evidence that fluoride is safe.” “How do you know thatthe speaker really did all the work thatway and that these aren’t just the threebest cases out of a couple dozen?” “I havebeen using the sledgehammer technique

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Leadership

for years. You have not bothered to lookat ALL of my results, have you?” “Youdon’t know everything.”

There is a very clever sleight of handin the argument from ignorance. Itworks like this: “If you do not have proofpositive that I am wrong, you had betterkeep your opinions to yourself. I amright unless you can demonstrate other-wise.” This is the “reasonable doubt”defense, but without overstressing the“reasonable” part. The correct logic isthat a claim for which there is not conclusive evidence one way or theother is neither known to be true orfalse—depending on one’s preferences.The argument from ignorance places aninappropriate burden of proof on thedenier. The burden should be on the person making the claim. That is howwe get so many folks believing in Big Foot, flying saucers, and 15% guar-anteed return investments. There is no irrefutable positive proof that itmight not be so. All scientific claims are vulnerable to this challenge becauseit is impossible to prove the nonexistenceof anything (except logically).

Assuming a Possible Outcome as Certain“I don’t think either of us could live with ourselves if we voted this down andsomebody died.” “Think of what mighthappen if you are wrong.” “Somebodyshould have known about the risks atthe embassy, somebody should haveknown that this thing about the wire-tapping would get out, somebody shouldhave check out Snowden. I want to getSomebody in front of our committee this week and I want some answers.” “I told you so.”

The most savvy individuals inAmerica regarding how to make moneyare not the hedge fund operators. Theyare the lottery winners. Megamillions on

a few dollars. Warren Buffet, eat yourheart out, piker. The odds are better than 50:50 that at least every two monthsin this country a single individual willwin TWO million-dollar-plus jackpots. Of course the chances of you or I winning like this are infinitesimal.What’s wrong with us?

Sometimes this is called “hindsightbias.” But it cuts a bit more deeply and is somewhat more treacherous. Whenwe base our before-the-fact decisions onassumed after-the-fact data we are onturf we are not entitled to.

Begging the Question“Let’s start with a straightforward premise. Everyone here wants better oral health. My plan promotes oralhealth. It seems to me that no one could be against my plan without beinghypocritical.” “If we could only find acandidate as honorable and noble as Dr.Clayfeet, our program would be certainto advance.” “How can we stop youngdentists from being unethical?” “Here ismy recommendation for how to use dietto live a long, healthy life: eat spaghettiwith lots of garlic for 100 years.”

Begging the question is a trick question. It is not pointing out that ananswer must be given. “Calling the question” is a parliamentary procedureintended to end discussion and move toa vote. “Begging the question” meanspresenting an argument in the form of aquestion that contains the answer one isseeking. It is Trojan horse argument.Once the question has been let into thediscussion, the outcome is prejudiced.“Have you finally stopped beating yourwife” is the classic.

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The conclusions of EBD

can still be dangerously

wrong, even when the

evidence is ironclad.

There are two good defenses against aquestion that is being begged. First, andpoliticians are getting good at this now,“I do not believe I would characterize thematter just the way you have…” Second,“Man, there are a whole lot of conse-quences and considerations that followfrom what you just said. What a greatquestion. Let’s see if we can lay out allthe implications here.”

When the speaker steps to the podiumat the begging of a talk and asks, “Caneverybody hear me?’ He or she is begginga question. Anyone who answers onbehalf of “everyone” heard the questionbut did not understand it.

Commitment to Lost Causes“Look, we have gone so far, it would be a shame to turn back now.” “I have nointention of letting anyone make melook like a fool.” “I really could havegone either way on this, but as long asyou are going to take that attitude, Ithink you need to know…” “It has beentails five times in a row. It only stands to logic that the odds are now muchgreater that it will be heads.”

Commitment to lost causes is aquaint human characteristic. Theseauthors were all considered unpublish-able during the early part of theircareers: Margaret Mitchell, HermanMelville, J. K. Rowling, Beatrix Potter, H. G. Wells, Ayn Rand, Rudyard Kipling,Shel Silverstein, John Grisham, andAgatha Christie. I am glad they were per-sistent. The very much more numerousnameless ones who pestered editors

with real trash deserve the fame they donot have. Commitment to a lost cause isa sneaky form of fallacy.

Technically, there may be nothingwrong with any single decision in theargument. Where the danger comes isthe serial sequence of decisions. Thenature of the decision fails to appropri-ately consider previous attempts. Somepeople cannot stand to lose even a smallargument or to be thought wrong abouta minor point. They play double or nothing in hopes of covering these losses.This is something like the sunk cost fallacy in business. When consideringwhether to proceed with an investment,the previous costs are irrelevant. Oneshould start from scratch at each decisionpoint and ask whether the additionalfunds to be invested now justify the currently expected outcome.

Disjunction“He’s an academic. You know it’s a factthat many of them have rusty clinicalskills through disuse. A lot of them favormid-level providers. The rate of ADAmembership is depressed in the schools.He probably is a non-ADA member withlousy clinical skill who favors mid-levelproviders.” “I read in the literature thatthe odds of having X condition are 20% for those from Group A and 5% ofhaving condition Y. I know the chancesof having both are less than 25%, maybe22 or 23%.” “When it starts to go bad, itgoes bad all the way.”

This is one of the most famous littlefallacies in the literature. The legendaryexample is called “Linda.” It goes like this.“Linda is thirty-one years old, single, out-spoken, and very bright. She majored inphilosophy. As a student, she was deeplyconcerned with issues of discriminationand social justice, and also participatedin antinuclear demonstrations.”Respondents are asked to read thisdescription and then rank order the

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More men will opt forheart surgery when theyknow that it has a 90%success rate than if they are told that there is a one in ten chance of fatality.

following descriptions of Linda from themost to the least likely: (a) elementaryschool teacher, (b) works in a bookstoreand takes yoga classes, (c) active in thefeminist movement, (d) psychiatricsocial worker, (e) member of the Leagueof Women Voters, (f) bank teller, (g)insurance salesperson (h) bank tellerand active in the feminist movement.There is no right or wrong answerbecause there is no Linda. But what isinteresting is the fact that 85% ofStanford graduate students believe it ismore likely that Linda is (h) a bankteller who is active in feminist causesthan that she is (f) a bank teller.

It is logically impossible for the combination of two events to be ofgreater likelihood than either of theevents occurring alone. It is not a matterof this being unlikely; it just cannot be.We naturally, but erroneously, sumacross probabilities instead of multiply-ing them. We fashion stereotype bucketsand then throw everything that looksclose into the buckets. The messy fact is that more details make the picturefuzzier, not clearer. Don’t pile on.

Don’t Mess with Success“The characteristics that made dentistrygreat in previous generations are exactlythe characteristics that will keep itgreat.” “The way we do dentistry aroundhere works fine for us and it shouldwork fine for you too. If you know whatI mean.” “If it ain’t broke…”

All true claims are relative to theenvironment in which they are expectedto work. It is just as pig-headed to try toforce others to change because a newidea worked in one location as it is tocling to outdated notions when theworld has moved on. The key to finding

the difference has little to do with thequality of the idea or the evidence itself.We must become talented at reading the context.

False Analogy“Using Wonder Stuff makes you a virtu-oso of the dental art.” “Holding dentaleducators responsible for the clinicalcompetence of their graduates is like setting the fox to guard the henhouse.”“What we need is a war on poverty.”

You know an analogy is comingwhen someone uses words such as “thatreminds me of” or “this is just a case of.”Sometimes analogies are buried inhomey stories; sometimes they areadvertising slogans. The point of usingan analogy in an argument is that itscalls to mind a stereotypical prior pat-tern with an implication that we eitheralready know how to handle these orwhat dangers to look out for. A goodanalogy is useful for highlighting someof the key features of an issue. A bad oneis dysfunctional because it misclassifiesthe situation. This would be a case ofsaying that all faulty arguments are likethe blind leading the blind.

False Continuum“Let’s not consider the radical surgerybecause there are always varying degreesof danger.” “The problem with you isthat you make everything black andwhite. There are always shades of gray.”“No, I think I’m just a little bit pregnant.”

Decisions—commitments to action—are dichotomous. We buy a luxury car or an economy car. We cannot buy aninexpensive luxury car. Not seeing all the features we want in one package ornot being able to detect a big, brightboundary line predisposes us to take noaction. A good way to block an actionone resists is to begin pointing out theporous edges, the unclear distinctions,

and the impossibility of getting exactmeasures. Usually a call for further study is a motion to kill by appointing a committee to document the vaguenessof the idea.

False Dichotomy“Either he is a conniving scoundrel or heis a fool.” “You need to have that toothrestored with an amalgam or a compos-ite filling. Since amalgams show metal,we should probably go with the compos-ite (or alternatively, since compositestend not to last as long, we should useamalgam).” “Time is running out. Wehave to make a decision one way or theother.” “If you really love me, you willtake me to see pro wrestling.” “I thinkwe should go for plan A because it onlycosts $50,000. I’m sure there are thosewho could figure out how to spend$75,000. Don’t you think it is good tosave $25,000?”

Part of this is very good logic: EitherA or B, not A, therefore B. Air tight! Sowhat is wrong with the false dichotomy?It is either good logic or it is not. Theproblem is that the major premise maynot adequately describe the situation. Inmany cases where A and B are at issue,there is also a C or even a D. Perhaps thebest choice is not even on the table yet.Perhaps there really are only two, butthey are A and E. False dichotomy isoften attempted when an individual sees that Plan A, which is distasteful, isheaded for adoption. If the matter can be reframed between Plan B or Plan C,the antagonist to Plan A will have pulled a fast one.

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When you hear ultimatum languagesuch as “either,” “must,” or “well, whichis it?” immediately ask whether there are other alternatives that have not been considered yet.

Inconsistent Criteria“I know I said a while ago that I don’tput much stock in government statistics,but in this case I think they have it exactlyright.” “We have always been doing itthis way for no particular reason, but itwould only be prudent to demand a veryhigh standard of evidence if we were toconsider making changes.” “All we haveto do is make a generally plausible case.”“Beat your plowshares into swords…[Joel 3:10] Beat your swords into plow-shares [Isaiah 2:4]”

It is unnecessary to give any strongerreasons for one’s position than wewould expect of others. Ralph WaldoEmerson’s advice about the hobgoblinsof small minds only applied to “foolishinconsistencies.” If we never changedour minds about how to think, none of us would have gotten out of kinder-garten. But trying to maintain both sideson an inconsistent position at the sametime will be a sure signal to our friendsthat we need to tighten some of the bolts on the mental equipment.

The J-Shaped Curve“As I recall, the first committees wereformed in the 1960s and they were notthis organization, but some of the officerswho are also with a different group.” “If we check the records I think you willfind that I am right about this.” “Mostpeople in this room know a lot less thanthey think they do.”

The human memory is a shaky foundation for grounding decisions. The foundational difficulty is that weoverestimate how secure the foundationis. Research shows that we claim to

know 98% of the facts on typical tests ofgeneral knowledge, but we actually areaccurate about 80% of the time. Orsomething like that. There’s a danger inacting on that gap. Actually, we some-times underestimate our general factualknowledge as well. That is the meaningof the J-shaped curve. We underestimatehow much we know of the easy stuffand overestimate how accurate we arewith the difficult material. (If we plotconfidence on the vertical axis and difficulty of the material—as a functionof how many others get it right—on the horizontal axis, the scatter of thepoints forms a J.)

The lesson is clear: if you are unsure,look it up. And if it really matters, makeabsolutely sure to look it up. [Griffin, D.& Tversky, A. (1992). The weighing of evidence and the determinants of confi-dence. Cognitive Psychology, 24 (3),411-435. I was wrong. When subjectsknow 80% of the facts, they claim toknow 99% of them—on average!]

Missing Premise“All things are possible to those whobelieve. Perhaps you weren’t believinghard enough just now.” “I can explainthat, we just have to assume…” “The reason you cannot see examples of ESPis that disbelievers have traces of thatknowledge erased.” “You cannot beexpected to be in touch with the truefeelings of young dentists because youare an old one, and they are not going to let you in on their secrets.”

The missing premise is a universalcure-all. It is the trump card in reasoning.If one comes up short, all that is neededis to hypothesize the existence of onemore fact that would explain the

discrepancy. This might seem to be nothing more than a holding tactic, butwait… If you get good at this sort ofthing, it can really work. “Do you haveany bullet-proof evidence that every conceivable test for toxicity of amalgamhas been tried? Aha!” Even better is themissing premise that cannot be verified.“The reason that I cannot prove the efficacy of thalidomide is that the government has banned research on it.”The latter kind of argument is called aself-sealing missing premise. It is good to carry a few of these in your wallet incase of emergencies.

Moving the Goal Posts“Well, of course everyone is happy thatthe Deltas have agreed to cut back onthe types of cases they are going toreview, but it doesn’t go nearly farenough,” “Sure, there are a few studiesthat show, under very particular circum-stances, that ARC is safe and effective,but there is nothing like a demonstrationthat such would be the case generally.”“You show me your best evidence and I’ll tell you whether I think it is good enough.”

The description “moving the goalposts” is not quite right. The goalremains the same for those who takecover under this trick. They always haveand always want to maintain their general claim. To do so they must ruleout any evidence to the contrary. If the evidence itself cannot be faulted, perhaps it can be ruled out of court asnot addressing the deepest concerns.What has changed is their public pricefor surrendering their position. One suspects that this price is really infiniteand the real purpose in moving the goalposts is getting others to quit the game.

Non Sequitur“I know we have been talking about adues increase, but I would like us not to lose sight of changing membership

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profiles.” “We have been talking so muchabout my research funding. I’d like tohear a little about your views. What didyou think of my latest research paper in JADA?” “The consensus is that the evidence places candidates A or B at thetop of the list, but I don’t really like either,so I suggest we go with C.” “As a dentist,he is one marvelous clarinet player.”

Non sequitur means “it does not follow.” That can include everythingfrom just drifting off in the meeting andcoming back in on the wrong page tofaulty logic of any type to changing thetopic inappropriately to substitutingone’s own definition of the issue underconsideration for the common under-standing others have been workingwith. If a rational person who has beentracking the argument up to that point issurprised by what you say next, there isa very good chance that you have justpulled a non sequitur. It is not so muchmuffed ratiocination as poor listening.

No True Scotsman“All Scotsmen have a chip on their shoulder and are willing to defend theirhonor at the drop of an insult. Well,McPherson seems like an easygoing fellow. But he’s not a true Scotsman.”“Because recent grads are so much indebt for their dental education, they tend to cut corners, overtreat, and joincorporate dental practices. There may be exceptions, but the rule still holds.” “I have been treating all my patientswith X for years. Never a complaint,except for a few sorta strange folks.”

The No True Scotsman argument issimply a matter of refusing to creditexamples that run counter to one’sfavorite generalization. This dodge keepsthe generalizations intact. In fact, I cannot think offhand of any plausibleexceptions to this.

Partial Reasons“Small businesses create jobs, so whateveris good for small business is good for the country.” ”The research evidence isoverwhelming that sealants are a cost-effective means of lowering caries rate,therefore every dentist should performthis procedures on all patients for whichit is indicated.” “Hey, Mikey likes it!”

How could anybody be against asound argument? This one is scarybecause a lot of deer have been run overwhile transfixed by the light of perfectlyclear statements. The misstep comes inequating a sound reason for the best reason. An argument may be entirelytrue, but some other arguments mightalso be true and more to the point. IfMikey likes whatever cereal, he shouldeat it (not me), but only if there is noth-ing better available for breakfast. It isimportant to get all the considerationson the table early to avoid the trap ofinvestigating the veracity of an ambigu-ous but unimportant claim, finding thatthe claim is either true or false, andmaking the entire decision on the out-come of the investigation. The claimmay not have been pivotal to begin with,even if there was heated debate aboutwhether it was defensible. Bewareunreasonable narrowing of the question.

Groups are especially vulnerable to“the trap of the debatable second-bestargument.” Dr. Easyanswer proposes apatchwork way forward. The committeebalks. Dr. Easyanswer offers to provethat his system is at least free from theobjections that have been raised. After athorough investigation, it is determined

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We fashion stereotype

buckets and then throw

everything that looks close

into the buckets. The messy

fact is that more details

make the picture fuzzier

not clearer. Don’t pile on.

that Easyanswer’s method is not fatallyflawed by the origianl arguments raised against it. The pressure to goEasyanswer’s way must be resisted.Although a lot of psychic energy wentinto a battle that Easyanswer won that does not mean other paths mightnot be better.

Incidentally, it is true that small businesses create the most jobs. It is also true that they create the mostunemployment. They churn.

Post Hoc Ergo Propter Hoc“Have you ever noticed how the odds of something unfortunate happeningalways seem to go up when we try newideas?” “We have a pretty successfulmembership promotion program. Eachyear we give a list of those who have notpaid their dues to a few volunteers. Idon’t know what the volunteers do, butwe always get some of these folks tocome back.” “I’m sure we won the WorldSeries because a bunch of us made apromise not to change our underwearuntil we had.”

The Latin translates roughly: “Afterthe fact, therefore because of the fact.”The fallacy is to attribute a causal relationship to a temporal coincidence. It is true that causes always precedetheir consequences, but it is not true thateverything that precedes a consequencewas part of the cause.

A form of this fallacy that is dear tothe hearts of so many statisticians iscalled regression toward the mean. Itworks like this. Begin with a pool of subjects, programs, or other items thatcan be arranged from the best to theworst and find the average value. Nowpick the bottom 10% and do nothing

else. Measure the bottom 10% again and you will find that their scores haveimproved on average. I guarantee it!They have regressed toward the mean.This is not magic. It is just a result ofhaving misclassified a few of the folks inthe bottom group because the originalmeasurement system was not perfect.The same will happen at the top—theywill drop toward the middle on subse-quent measurement. Sometimes theplacebo effect gets credit for nothingmore than inexact initial diagnosis.Some pretty strange remedial programshave received high praise for just hap-pening to be hanging around whenfaulty data were gathered.

Red Herring“Gun registration makes no sensebecause crazy people need mental healthhelp.” “There is little value in courses onethics in dental school because studentshave formed their ethical values duringchildhood, if they are going to have any.” “Before we get too deep in the merits of the proposal, I want to explorea completely irrelevant matter.”

There was a time when riding to thehounds became too tame. True gentle-men wanted to give the foxes a moresporting chance. They sent the staff outearly in the morning to drag dead fisharound the park to mask the scent of thefoxes and thus challenge dogs a little.The most typical fish used for this purpose was a red herring. The point of this deflected straight thinking is tosubstitute a faux issue for the real one.You know you are about to enjoy a dinner of red herring as soon as youhear “But I think the real question is…”Red herrings become very plentifulwhen one party wants to avoid a courseof action and the other party has aneffective but compromised solution. Thestrategy is to note that solving a differentproblem would produce much morefavorable results, but since the more

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Trying to maintain bothsides on an inconsistentposition at the same time will be a sure signalto our friends that weneed to tighten some of the bolts on the mental equipment.

attractive solution is not workable, we hadbest just not do anything. Red herringsare abundant in the Potomac River and can be studied to one’s great benefitby looking in the Congressional Recordunder the heading of “poison pillamendments.”

Resemblance“It is certainly more likely that a daughterwill have blue eyes if her mother doesthan that a mother will have blue eyes ifher mother does.” “There are probablymore murders each year in Detroit thanthere are in Michigan because Michiganhas a high overall rate of literacy.” “I canrecall a lot more studies that show thesuperiority of X than Y.” “Most newbornbabies look like Winston Churchill.”

We exaggerate the familiar. We recallour successes. We overestimate the dra-matic. The term “like,” as in looking likeWinston Churchill, is a relative term andsafe because there will always be somepositive examples. So many people diedneedlessly following 9-11 because theywere afraid to fly. They drove instead,and because driving is more dangerous,the deaths while traveling between cities increased. Confirmation bias is anexample of resemblance. We see whatwe expect to see, and remember what isuseful to our purposes. Research studieswith statistically significant results aremore likely to be published. And thechances of a mother and daughter having any inherited characteristic areexactly symmetrical.

Because of resemblance we tend tosolve the problem we are familiar withrather than the problem we actuallyface. Here is an example: A bat and ballcost $1.10. The bat costs one dollar morethan the ball. How much does the ballcost? Hint: if you said ten cents, stay outof the stock market or poker games. Youare a mark.

Selective Use of Evidence“All women are bad drivers, or at leastthose I know well are.” “I finally found atelevision station that gives me the newsstraight—Was it CNN or PBS?” “You justhave to hear Dr. Pontificator or read theJournal of Fabulous Results.” “Whateveryou do, don’t look at their Web site.”

This one is so obvious that there isreally only one side of the issue…or… We need to have a consistent point ofview as a basis for starting our criticalappraisal of any issue. When we cruisearound with a completely open mind,things fall out. But there is always achance of fooling ourselves and trying to fool others by privileging selectivesources of information. This problemcan become self-reinforcing. We naturallylook for and listen better to informationthat reinforces our existing beliefs thanto those that challenge them.

Here is an approach that might be of some use. Learn one perspective andlearn it well. Then look for what youbelieve might be the strongest contrarypoint of view. Combine them based ontheir relative merits. Of course your original perspective will still predominate,as it should. Find another perspectivethat differs from both you have consid-ered. Integrate it. Continue the processuntil additional information seems to be contributing little to your under-standing of the issue.

Here is another strategy. Ask that all opinions (actions not arguments) belaid on the table. Identify the one thatirritates you the most. Try to paraphraseit so that its proponents agree that youhave understood it. Continue the process.

Finally, when stating your conclusion,mention the strengths of other positions

you have explored. If you have not lookedat other positions or cannot accuratelycharacterize them, say so (and watchfolks push back from the table).Remember you are looking for a betterposition. “Better” is a relative term and is vacuous unless you have made the relevant comparisons.

Slippery Slope“Well, I don’t know. It sounds like wemight be establishing an undesirableprecedent here.” “First it’s going to bejust a few little things, and then therewill be more, and before you know it wewill have agreed to give away the farm.”“This one change seems fine, but whoknows where it will all end?’

Slippery slope is based on a verysound psychological principle. Habitua-tion is the natural process of letting ourstandards drift to accommodate the newreality. The Victorians were right to beworried about letting women show theirshoes in public. If they had only been abit firmer, we would have been sparedLady Gaga. Never mind the barebosomed women of fashion in the lateeighteenth century. That was a slope inthe other direction.

I am sympathetic to the slipperyslope argument because there are caseswhere small concessions lead to abuse. It is not, however, a generally valid formof argument. If it were, there would beno human progress. Most reasonablechange should be incremental. To throwout gradual change is to kill innovation.What is needed is willingness to makethe hard judgment calls about howmuch change is appropriate at themoment and not hide in an imagedfuture. We must all trust the leaders whofollow us to make the hard judgmentcalls of their day. The slippery slopeargument fails when we make our

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choices easier today by usurping thechoices future leaders will have to makein their time.

Special Pleading“I appreciate the fact that researchshows the superiority of approach X, butperhaps we shouldn’t be hasty. I havepersonal experience with this.” “Speedlimits are fine for most people, but theyshould not always be enforced.” “Thereare lies, damn lies, and statistics.”

Special pleading is about dealingoneself an exemption. It is soothingbecause no effort is made to challengethe facts or the principles presented. “Weall agree in theory…” One just sidestepsthe matter by saying that the rule maynot apply in inconvenient cases. One ofthe all-time virtuoso cases of specialpleading concerns King David. Heseduced a married woman namedBathsheba. Then he arranged to haveher husband disposed of by placing himin the front lines of a battle. The priestNathan confronted him by recounting astory of a rich man with many sheepwho stole the only sheep of a poor man.David blustered that he would kill thatscoundrel if Nathan would be kindenough to reveal his identity. David gotthe bad news but made a special plead-ing to the king (himself) and that is whyKing Solomon, the son of Bathsheba,was allowed to build the temple and hisfather was not. You know it is time toreach for your “special pleading bib”when someone starts, “Well, I’m noexpert, but …” or “Are you certain that isalways true?”

Spurious Correlation“The CIA has tracked income disparitiesin countries since the 1940s becausegreater wealth at the top is associatedwith and causes political instability.”“The proportion of dentists who arewomen and the percentage of dentistswho are members of the ADA areinversely associated, showing thatwomen are less professional.” “We conclude that smoking causes cancerbecause thousands of studies haveshown that the more one smokes themore one is likely to die of cancer.”

It is worth a few points at gatheringsof researchers to casually mention that“correlation does not prove causation.”Mostly that is true. There are three classically accepted criteria for demon-strating causation. Co-occurrence(correlation is co-occurrence). The causemust also precede the effect and thereshould be no other factors that couldhave affected the relationship but haveescaped notice. The latter is a high bar.When there are other factors that mightbe working, that is called a serious corre-lation. The tobacco industry tried thatone: there might be genetic or environ-mental factors that cause cancer andalso cause people to smoke. They eventried to say that cancer causes smoking.I subscribe to the argument of someresearchers who want to see a fourthstandard for claiming causation. Thereshould be a plausible theoretical accountof the mechanism of operation.Incidentally, proof of the causal relation-ship between smoking and cancer hasfinally been demonstrated using correla-tional methods. After all, RCTs in thisarea are strictly out of the question onethical grounds. But good statisticianswith multiple regression techniqueshave assembled overwhelming evidence.

The danger of relying on correlationsin decision making when there is a riskthat the association is spurious is thattime, money, and effort will be invested

in the null variable. Changing the factorthat is along for the ride rather than theone that is driving the phenomenon willbe a waste of resources.

Straw Man“I think I have just shown conclusivelythat you are wrong on any plausibleinterpretation of your position.” “No onewould hold a ridiculous position likethat.” “I think the evidence is pretty substantial that school lunch programshave been a failure in reducing the incidence of obesity in America.”

The straw man is a substitute for thereal antagonist. It is usually easier topoke holes in a position that no oneactually defends. Getting a victory thereis not a wasted effort; the other party—regardless of the strength of his or hertrue position—is now on the defensivetrying to explain what the real issuewas. In the last presidential campaign,billions of dollars were spent by eachparty telling us why one of two trumped-up dummies would be ruinous to thecountry. The folks in the attack ads werecaricatures. The Supreme Court, by avote of 5 to 4 in the Citizens United decision, declared the straw man to be the new American. Unlimited andundisclosed funds can be spent on political advertising, provided that theadvertising does not actually endorse acandidate who is running. That onlyleaves bashing an effigy of the other guy.

Tautology“Reasonable people will see the wisdomof this position.” “We need to consideronly those prudent actions that willadvance the common good.” “I am doingthis because I believe it is the right thingto do.” “I will get the material to you assoon as possible.”

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A tautology is a claim that is truebecause of the meaning of the words,not because of the facts. Learning thatour motion was defeated because theother side had more votes, does little toadvance our understanding. Corporateliterature is filled with this stuff.Companies do not apologize for failureof safety standards that have resulted indeaths; they issue press releases statingthat their corporate policy is to promotethe highest level of integrity and socialwelfare. It is not fallacious reasoning(both may be true); it is empty calories.Tautologies are red flags that bear careful monitoring. It is the sentencethat immediately follows the true-by-definition claim that has the hook in it.

True Because I Want It to Be True“The evidence that DHATs can do someprocedures safely and effectively needs tobe replicated before it can be accepted.But we are opposed to conducting suchstudies because we do not believe that isright.” “We do not disagree. You justhaven’t seen the wisdom of my positionyet.” “Inconvenient truths are a pain inthe anatomy.” “This is the only thingthat makes sense to me. If you deny this,the whole system just does not seemright,” “I have my own reasons, and,trust me, they are good ones.”

This is likely the most pernicious ofthe fallacies. Georgetown bioethicistEdwin Pellegrino classifies this as aspecies of unethical behavior, not faultyreasoning. To make a public claim basedon wanting it to be true, and hoping others will not counter it, certainlyappears to be fishy. Proving that there isa bad-faith motive is impossible. Only we and our consciences know aboutthese sorts of things. But in the spirit ofopen reasoning about public matters, all of the motives should be available forinspection. If a better argument cancarry the day—hurrah.

What is Unexplained isUnexplainable“The reason all patients cannot bebrought to good oral health is that wecannot control human behavior—at least not other people’s.” “If we weresupposed to be practicing preventive bio-logical or genetic dentistry rather thanmechanical repair of teeth someonewould have found the evidence by now.”“Now would be the right time for folkswho still believe in the safety of amalgamsto produce their conclusive evidence. Wecan only assume that since they havenot done so, there is no such evidence.”“You can lead a horse to water…”

It is one thing to know that some-thing is impossible and another to note that it has not yet been done.“Impossible” ≠ “Unknown.”

There are some very famous “impossibility” or “indeterminacyproofs.” These are rigorous argumentsthat, starting from a plausible commonbase, certain destinations cannot bereached. Kurt Gödel proved that ourunderstanding of common numbers can be either complete or consistent—but not both at the same time. WernerHeisenberg proved that, in quantumphysics, we can know the location of aparticle or its speed and direction, butnot both at the same time. KennethArrow proved that three people cannotagree on how to prioritize welfare bene-fits over more than two alternatives.

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The missing premise is a

universal cure-all. It is the

trump card in reasoning.

If one comes up short,

all that is needed is to

hypothesize the existence

of one more fact that would

explain the discrepancy.

You Too“Bringing charges against me for havingsex with an underage girl named Roxy is politically motivated.” “Your argumentis about as old and moth-eaten as yousay mine is.” “You have your expertise, I have mine; you think you see gaps in my logic, they clearly are not the flubs we have been hearing from youthis afternoon.”

A good counterattack can drawattention away from a flimsy argument.Of course it is gummy logic. It does notmake my argument true even if I provethat yours is false. This approach doesgain a bit of traction when the samemotive or even the same evidence is citedby both sides for diverse conclusions.

The high-brow denomination for this fallacy is tu quoque. The com-mon moniker is “the pot calling thekettle black.”

The Fallacy Fallacy“Got ya!” “We are recommending againstpublication of your manuscript becausethe eigenvalue of the Varimax factorrotation has not been specified.” “Logicalfallacies have broken loose and are running amuck in American. If I had tothrow out every claim that I know isbased on fallacious reasoning, therewould be nothing left to believe.”

Yes, there really is a fallacy fallacy.Philosophers mention it from time totime in order to add gravitas to theirpapers. The fact that a position has beendefended by a fallacious argument—recognized as such or not—does notmean that the position is false. Even a

blind pig finds a truffle every now andagain. We should not get too uppityabout fallacies.

Putting this as strongly and as positively as possible, the purpose of reasoned discussion is not to poke holesin others’ positions. Why we cometogether after studying the issues ascarefully as we can is to find the solidarguments. We are after the good stuff.Although being bright about fallacies in reasoning is a handy and necessarytool in this process, no one ever reliablyreasoned his or her way to the smartthing to do by making fun of others’sloppy thinking. It would be fallacious to think so.

A SuggestionUse this dictionary when reading the scientific literature, watching the news(especially the talking-heads shows),and at meetings. Make a photocopy andtake it to your next committee meeting. I am pretty certain it will make you abetter listener even if it does not makeyou the most popular person in theroom. And remember, it is better to findyour own faults in thinking than to letothers do the job for you. ■

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We need to have a consistent point of view as a basis for starting our critical appraisal ofany issue. When wecruise around with a completely open mind,things fall out.

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