 Okay, I'm Dave Chambers and I'm glad to see you here. This is the American College of Dentist Ethics Report program on the new profession. I have a little problem with this presentation. First of all, you're the wrong audience. The people who need to hear this thing about ethics are not the people like you who are the most ethical in the profession. Another little problem I have is that ethics takes place in the dental office. It doesn't take place in lecture hall or a Zoom conference and so forth. And the third restriction is that I'm not going to tell you what to do. That isn't how ethics works. And then there's the matter of the conflict of interest statement. This is required for all these courses. And I've been giving ethics presentations for 20 years or longer and no company has ever approached me saying they have some money to support that kind of thing. So there's no conflicts of interest here. That's a picture of the book. The Ethics Report, new professionalism that the American College of Dentist put together. It's 500 pages long, but we'll do the short version here. The project started five years ago when the Board of Regents of the College said to the editor, we'd like to have a book length report on ethics in dentistry. And we want it data-based like Geis did with his report. We also wanted to be positive in the sense of looking for opportunities to elevate the ethics in the profession. And some people got behind that. One person in particular is a late Jerome Miller, and he was so passionate about it. He said, I'll give you a million dollars if you find a million dollars among the others in the college. You are interested in ethics. And we did. And that tells everybody that this is very important to the college. Director Miller always used to say, have you got a little skin in the game? And that's what he was referring to. And so we're going to talk in the next hour about getting some skin in the game. The approach that we took with the project was to listen. We started by listening, and we continued to listen. And we listened to everybody except possibly a few. We didn't listen to experts very much. We did literature searches primarily in professional ethics and organizational ethics. And we did research studies, about 11 of them. And these were published in peer-reviewed journals. You can read them there. And the intent of the project was to diagnose what the problem is. You can read 510 pages and you won't find a single recommendation in there. It's not about asking other people to help us. It's about saying what is the problem and what are we going to do to fix it? So here's the conclusions of the presentation. The context of dentistry is changing more rapidly than dentistry is responding to that. Being individual dentists in ethical theory is fine, but it's not enough. And the profession has to respond with action and as a profession. Here's the plan for the presentation we're doing now. We've just been oriented. We're going to talk about the listening we did. We're going to talk about what it means to practice dentistry. Some of the things that dentists do in terms of ethical behavior. Four approaches to being ethical and then how we might proceed. So Stephen Covey popularized a common story that we tell. And it's about a patient whose eyesight began to fail. And the patient went to the optometrist and said, doctor, I can't see quite as well as I used to. And the optometrist immediately reached inside the desk drawer in front of him. And he pulled out a pair of glasses and handed it to the patient. He says, here, try these. And the patient says, well, wait a minute, doctor. Aren't you going to do some tests? Aren't you going to find out what special problems I have and so forth? And the optometrist says, oh, don't worry about that sort of stuff. These glasses work great for me. So we listened. And we listened to a lot of people in focus groups around the country. We had eight groups of patients, California, Ohio, North Carolina and Oklahoma. And these were put together by the Citizens Advocacy Council. And that's a group in Washington DC that represents state boards in various professions. We had four groups of practitioners, about two thirds of each group being ADA members. We had professional leaders in the various states. And these were selected by organized dentistry itself. We had some opinion leaders like ARP folks in Washington DC. And we filled in with some written surveys. The question we asked in each case was this. When you hear the words ethics and dentistry together, what do you think? Now that was the only question we asked. We didn't say, well, do you think this and do you think that and how many percent are this? We just asked that one question and it wrote down everything people said for about an hour and a half in each group. And the number one concern was over treatment. That wasn't just among patients. That was among the leaders in the profession. It was among the policy makers and so forth. The number two concern is outside values. People outside of dentistry are telling dentists what they ought to do. And some of them are listening. And the number three issue is that individuals practice solo. They practice independently. Now this is my favorite because the very first session I was in was with some young leaders that the association in Ohio said these are the people who are up and coming. And we asked the question of first response was, well dentists are independent. And I said, yeah, I know they're independent, but we wanted an ethical issue. Now surprisingly, the whole room erupted and says, you're not listening. Being independent is an ethical issue. If dentists don't agree with each other and tell patients different things, they don't agree with each other and bad mouth each other. Who are we going to believe? And if dentists want to hide in their own offices, how are we going to make them more ethical? A couple of things that didn't show up. Poor quality dental care was not an ethical issue. Not one person mentioned it. Dentists don't understand ethical theory. It's not an issue. Not one person mentioned it. Young dentists are unethical. And it's not too much of an issue. Some of the older dentists did say that. So the self image, what is the practice? What is licensure? How do people cheat? And so forth. Dentistry is a practice in what is called a professional services firm. Dentists don't add value to the community by selling things. They don't sell toothpaste. They don't go out and discover things like oil refiners do. They don't lecture to people and give them, you know, charge them for their opinion and so forth. Dentists practice and that's a technical term. The Greek word is technae. And it means the combination of art and craft. Art and craft. Dentists are the work that dentists do is skilled work. People can't do it. It's customized work is different for each patient. It's problem solving. It's not always done the same way, but it is done to standards. And dentistry is only done when people need it. People don't say, well, you know, I got some free time this afternoon. I think I'll go get an endo. They wait until there's a problem and then they go and ask for that problem to be attended to. And you can't run up an inventory in dentistry. You can't do 20 crowns this week because you might need a few extras next week. There's an asymmetry of information where the dentist knows a heck of a lot more about what's going on than the patient does. And there's direct contact. I can remember early on a dental student once asked me, doctor, should I touch my patient? I thought for a minute and I said, I hope you do. Relationships. It's not about a transaction. It's about what went on before, what's going to go on in the future and so forth. There is no one best treatment for any individual patient. There's a range. And in that range, all of them are appropriate. But the range is not unlimited. You have to do dentistry that's acceptable to your peers or there's a bigger range if you wanted to do anything that's legal or there's a smaller range if you wanted to do anything supported by evidence-based dentistry. But professional services firms are licensed by states, different licensure in different states. They're not licensed by dental schools. They're not licensed by the profession. They're licensed by states and the state says you can have an economic opportunity to serve the public. These licenses go to real estate agents and building contractors. Anybody where the public can't tell exactly what's going on with the professional services firm. The professional services firm, some of them are good and some of them are bad. But surprisingly, quality is not the issue. Quality is assumed. Every patient we talk to said, well, I go to the dentist because I know the dentist can do the work. That isn't the issue. In fact, the ADA says you better not tell a patient that the guy isn't up to quality. We don't compete on price in professional service firms. If you compete on price, you are going to go to the lowest common denominator and you'll drive your colleagues to the lowest common denominator as well. And we don't compete on size. There's great little ones and great big ones as well. But what does make a professional services firm effective? One reason is they delegate. You delegate to the lowest paid person who is capable of performing the work. You offload as much as you can of the fixed costs like buildings and payroll and that sort of stuff. And you automate your records as much as you can. All of those things are going to add to the value for the dentist and for the patient. Now, here's a funny thing. If each of you told me how many auxiliaries you have in your office, I would tell you how much money you make. And I'd be pretty close to being right too. Because 70% of the difference between one dentist and another in terms of their income is a result of how well they delegate. Now, I recognize this is a problem because now we're beginning to get delegation of dentist to dentist delegation and some of those dentists aren't too happy about that. And we're getting delegation of dentists working for people who aren't dentists. And some people are like myself are worried about that. So I wrote a little editorial in the Journal of the American College of Dentists about that practice and I said beware of that, but it wasn't much of an editorial. It didn't do any good. You can see that that editorial was written in 1995. Another thing professional service firms can do is to find better customers. Resources like chair time are limited. That means you should use them where you can to maximize the benefit to the patient. The best customers are repeat customers. And I did a little mining on the internet to find out in California what the average income per household is and it's $62,000 or it was five years ago. Then I looked to see which census tracks in the state of California had a dentist and which ones didn't. And there's quite a few even counties in California that don't have any dentists at all. But the ones that do have dentists, the median household income is $69,000. In other words, dentists know where the better patients are. The third way that professional services firms thrive is through the monopoly. And that's the practice acts that say what dentists can do and what other people can't do, lobbying and so forth. You see, dentistry is not a free market profession. It's a highly regulated profession. In fact, it's one of the most regulated businesses we have and most of those regulations were put in place by dentistry itself. Let's look at discipline licenses. Now we're getting into some tender area here, but it's an opportunity for finding out how to make things better. Approximately a thousand dentists every year across the country have their licenses disciplined. That means that the state says you can't do that anymore. About 20 times the number are investigated by state investigatory agencies. Formal complaints against dentists are 100 times that. Each state regulates those professional activities differently. But a common denominator is that it's not a lack of ability that leads to a discipline license. It's the abuse of judgment on the dentist part. So I looked at 15% of the dental licenses that were disciplined over a period of time in California, North Carolina, Ohio and Oklahoma. And you can say, now wait a minute chambers, how did you know who had a discipline license? And the answer is that everyone knows who has a discipline license. In every state jurisdiction, it is a law that a discipline license is posted online for everybody in the state to read. And they run into 15, 20 pages, 30 pages of detail about this. And it's not happy reading, but you can read it. The technical issues, about a third of the cases were for technical reasons. Now this isn't underfill and it isn't overhangs. It's failure to diagnose. It's performing work for which there's no record that the patient in fact needs that work and so forth. The graph, and you'll see a couple more like this, the blue bars, the higher the bar, that means the greater the proportion in that age group of dentists who have discipline licenses for technical reasons. That's an unusual curve. It's not a normal curve. It's what we call a bimodal curve. And there's a big bump down there in the low end and a little bump at the high end. And these bumps correspond roughly to when one starts their own personal practice starting up the practice and then again ending the practice just before retirement. The biggest area of concern is patient management. And that's where the overtreatment comes in and that's where it comes in from billing for procedures that weren't done and that sort of stuff. The case management, the doing the veneers before the, before the perio. It's a lack of informed consent. It's abandoning patients in the middle of treatment. And you can see that again there's that bimodal distribution, the beginning of practice of one's own practice, not the beginning of practice of dentistry and then towards the end. And then there are personal issues. Dentists are a lot like people and some of them go out and drive their cars when they're drunk and they shouldn't do that. Some of them take drugs and prescribe drugs for their friends and some of them are cognitively impaired and don't know for sure what day it is and so forth. Some of them engage in sexual misconduct and then there's that famous one about too few CE hours and they commit crimes like auto theft and so forth. My favorite was a dentist who impersonated a enforcement officer for the Department of Consumer Affairs and sent notes to her colleagues saying, I'm going to come and visit your office and I want to see your charts. Well, she was blocked from practicing for a little while. But again, the same bimodal distribution. It is age related but not age related in the way one would normally think. Now that dashed line that goes across in the middle is the proportion of dentists in the United States by age. And you can see that there's more young ones and it tapers off as the older ones. Dentistry doesn't kill people, but we're increasing the number of dentists. So the new dentist, of course, is a young dentist. But very importantly, you look at that graph and you can see that discipline licenses are underrepresented in the young group. In fact, that's the same that we found when we looked at medicine and other fields. The average age of a discipline license among professionals is about 57. Now, who does that behavior that they shouldn't? The top line here is an important line because for every discipline dentist I found, I found a match dentist who is like that person in terms of where they are and how they practice and specialties and so forth. So we're looking for ones that don't have a discipline license across the top there and we can see that they don't have a lot of multiple offices and they don't have a lot of those fictitious business names. They aren't Dr. Wonderful or Magic Dental Office and that sort of thing. The ones that have technical and management problems do have multiple offices and they do have fictitious names and they do treat patients who don't have as much money as the other patients. So there's this thing about I think the dentists who aren't doing a good job. No, they're not doing a good job. And they're embarrassed about it and they hide from their patients and they hide by going from office to office and they hide by having a fictitious business name. About 40% of the dentists with fictitious with discipline licenses were ADA members but that's not a good number. The problem is that if you have a discipline license you'll drop your ADA membership or if you don't the ADA will probably drop you. Now the next slide I'm going to show you has very little information on it but it's something I'm quite proud of. I also look to see whether any of the fellows of the American College of Dentists have discipline licenses. And of course that will include you so here's the number. Justifiable criticism. The ethicists have said for a long time, it's one of the favorite things they say, is there's this implied social contract. I don't mind that it isn't written down anywhere but the idea is that everybody understands that society because it can't judge the quality of what professionals do grants a privilege to the profession to regulate themselves in exchange for the promise that the profession will police itself. As it's done, I'm not sure, the ADA has an item in the code which addresses that issue. And it says that dentists all dentists are always obliged to report gross and continuous faulty treatment and to inform the patient that there is something wrong in their mouth. It does not say that dentists should avoid criticizing their colleagues because they don't know what the conditions were under which the care was provided. It doesn't say that. But in the advisory opinion, which is kind of an appendix to the code, it does say that if you're not so sure about how this gross and faulty stuff came to be, you should go and talk to your colleague. And I think that advisory opinion is a very strong statement. It doesn't say rat on your colleague. It says go and talk to your colleague and see if we can make things a little better. Now, the patients in the profession don't see this matter the same way. The curve on the right, the one in blue is the response of dentists to the question, should you report gross or continuous faulty treatment? And the dentist kind of bunch up over in there, no way I'm not going to do that sort of thing. And the patients, and that's the orange line on the left, say, well, of course, I assume that all the dentists were doing that. Let's talk about the common good, because there is a common good in dentistry, something that dentists share among themselves. And I can ask, let me ask this question, is ethics an individual thing or a professional issue? And you're going to say, well, no, of course, it's both. And I say, okay, that's true, but you're not going to solve the problem, are you, unless you address the professional issue over and above the individual issue? You have to look to the common good. The way the common good game works, and we've done this in economics and sociology and criminology and all the rest, is that each contributes to the common good. We all do that. We all put in our best or next to best and so forth. And the public sees that and it judges the entire profession, not the individual, but the entire profession. Patients go to dentists because dentistry is good, and they know that it's good. So there's a common benefit, a reputation benefit for the whole profession, and it's equally distributed among all the members in the profession. Okay, there's a problem there, isn't there? Think about it for a minute. Free-riding means that you contribute less than your fair share, but you expect an equal reward. We've done this over and over again. It's all over the literature. I've done it with dentists. I've done it with residents and so forth. It always works the same way. You set up a situation where everybody puts in a little something, a little fake money or a little report on what they've done for their patients and so forth. And then you magnify that a little bit and give it back to everybody and equal shares. And what we find out is that at the beginning people put in pretty good amounts, but gradually they look around and say, wait a minute, I'm not getting what I expect out of this deal. I think somebody else is maybe not doing their fair share. So maybe I shouldn't have to do my fair share either, but I will get the common reward. And what happens over time, and it's usually a very short period of time, is that people stop contributing. That's pretty much every person for himself. That's pretty much that guy in Ohio who said, wait a minute, an ethical problem is that every dentist works for himself. Now we can fix this problem. It's pretty easy, very predictable. What you do is you say to the person you think who is a freerider, I think you're freeriding. I'm going to make it a little tough on you until you put in your fair share. And what happens is that the freeriders disappear and that everybody benefits more than they benefited in the first place. Now, I think you realize that Chambers just said something like, you got to punish your colleague for the common good. Well, I didn't quite say that. What I said is that for the good of the profession, you should pay attention to what your colleague is doing and help that colleague be a little better at it. You're not trying to kick the person out of the game. You're trying to show the person how to play the game better. So the common good may not be holding in dentistry. The membership in organized dentistry is going down. We're joining, writing our checks that we're not paying. We're not participating as much. And you say, well, of course, that's the way it is. In America, it's not a joining society anymore. People just don't join. And I say, well, that's true for some, and it's not true for others. For example, nurses are not losing membership. Lawyers are not losing membership. Evangelical churches are gaining membership. What about Amazon Prime? Some organizations are losing and some are holding steady. Every year, the Gallup Company does surveys of the public. It's called a professional trust survey and ask one question. Do you believe that people in this line of work have your best interests in mind? And they do that every four years for the profession. And you can see in the graph on the left what happens when they survey about nurses and so forth. And the nurses are always on the top. I think the nurses are always going to be the most trusted profession and physicians are trusted and pharmacists are trusted. But dentistry is the lowest trust among the health professions. So dentists could say, well, yeah, look, we may not be so bad. What's the numbers for lobbyists and numbers of Congress and PR people and marketers and insurance executives and lawyers? Well, that's on the graph on the right. We wouldn't want to be associated with those kinds of people at all. But as you can see, lawyers are making a run right now. They're on the upswing. The problem with the dental profession is it's becoming professionalized. Now that's a very difficult sentence to unravel. What it means is that the profession appeals to dentists, but it isn't run by dentists. Take a look at the morning huddle. That's, you know, I check every day, but Sunday I check the huddle to see what the profession is interested in. And the stops were not written by dentists. It's written by lawyers, PR experts, lobbyists, consultants. It's written by professionals in other professions. So the question is, is dentistry as an organization answering the profession's need for its identity? Or is it answering the profession's needs for services? And the answer is that they pay for lobbying. They offer the members credit cards, CE courses, spot news, the SELU insurance, and so forth. I was worried about that, so I looked at all of the ADA news since it's been published, and I just measured the amount of space devoted to advertising. And the amount of advertising has gone up. So the more advertising, the less membership. But then look at the identity side of things and say, well, how much of the ADA news is devoted to praising the work of dentists and letters to the editor and that sort of thing. And the more of that there is, the higher the participation. You can see the graph on the far right, that's age and proportion and membership. The number of members that are in the agency, the number of members that are in the agency, that's age and proportion and membership. The highest membership, of course, is the young group and the dental educators. The educators are overrepresented in ADA membership. It doesn't last, of course, because the young ones get a discount on their membership, and then they say, well, the services aren't worth what I'd have to pay in addition to get those. So the difference between recruiting and retaining and the profession has a retention problem right now. The graph in the upper right hand corner is ADA membership 1960 to now. And when I started in dentistry, the proportion of people who says, oh, I'm in an organized dentistry with 94, 95, 96% or something. And now it's down around 65%. I hope you don't think that I'm responsible for that drop. Question. Is ethics a matter of character or a matter of situation? You see, if ethics is a matter of character, it's really easy to fix the problem. You just get rid of the bad apples. And some people said, well, you know, the character was determined at grade school and the dental school should just keep those folks out. Here's the problem. If you put all the bad apples out, there wouldn't be many people left. You see, virtually all unethical behaviors performed by people who consider themselves to be basically ethical. The character they think is ethical, but sometimes the situation makes them unethical. I was, you know, maybe I shouldn't have done that, but you know, there was some pressure and it was a little ambiguous and no one was really hurt. And besides, I do sit darn much for everybody all the time. You know, I should get a little, you know, a little credit here. Enron, if you wanted to see a really great ethics statement, Google Enron Ethics. It's 42 pages long and it's excellent. Surveys show that over 90% of Americans say they have committed a felony or misdemeanor. They just haven't been caught. 40% say they cheat on their taxes. Two thirds of Fortune 500 companies have been caught by the federal government and they're working on that. White collar crime, that would be insurance fraud and over treating patients and so forth. Accounts for 25%, 25 times the damage to America as all of the street crime put together. Fraud, internal theft and so forth in your practice will be double what you lose due to bad debt. And dental schools do have cheating. There is cheating going on in dental schools, not as much as in nursing or law school and those other places. And it's going down in American dental schools. The peak year for cheating in dental school was 1979. Now, priming. We're still on the topic of is it a matter of character or is it a matter of situation? And of course, it's a matter of both. And we have a technical term in ethics for situational cheating. It's called fudging. And that's giving yourself a little credit because you think you deserve a little credit. And we've studied those things and we find, for example, you give you take students at Harvard and MIT bright young people and you give them a little math test and you say you score this math test and report to us how many you got right and we'll give you a reward. We'll pay you more money if you got a higher score and so forth. But they look and some of those page and some of those students they said, before you take the test, you're going to sign this pledge that you'll agree by the honor code at your school. And some of them they didn't because ethics is situational those who signed the pledge didn't cheat as much. That's pretty good. The problem is there is no ethics. There is no honor code at Harvard. There is no honor code at MIT. So it's not whether the whether it's an honor code is a question of whether you think there is an honor code. We do this more commonly by asking people name as many of the tunes that were popular in high school or name as many as you can of the 10 commandments before we give them one of these fudge tests. And what we find out repeatedly is that Americans don't know the 10 commandments. We did this with the American College of Dentists and at a board meeting we asked the regions to take a little survey on ethics and they did. And then we gave them the same survey a couple of months later and they scored higher on the survey when they were with a group of colleagues who were talking about ethics. And when they were individuals. Now that's something really important. There's a quick way of making sure that people are more ethical. You just put them in situations where they're talking about ethics with their colleagues. So the rule is whether you expect others to be ethical or not, you'll probably be right. Touchstones, ethical touchstones. That's a matter of what you're holding in your hands when you're making difficult decisions. Who do you consult? What do you consult when you're deciding whether you should take legal action against a former associate who's competing at a non-competition clause that are violating or discharging a patient who isn't paying his or her bills and so forth. And so we surveyed people and about half of them said, well, I'm not to talk with my colleagues or I'd like to talk with those people who were cheating on me. And that's good. That's excellent. Now what we see over there on the right hand side is there's some touchstones that people don't pay that much attention to. So what are they? Well, they're codes and principles and experts. The code and the ethical principles as beneficence and justice and that sort of stuff just don't carry that much weight practically. In fact, we surveyed the dentist and found that half of them don't know, we found that the ones we surveyed only knew half of the ADA code and some of them simply said, well, I just don't pay any attention to that anyway. And who knows the principles of bioethics? You don't know which ones you're not following, do you? And then the experts. You're going to stay away from the experts. The last thing you're going to want to do is ask a lawyer or heaven said, don't ask an ethicist. They might know the answer. It might be different from what you want. And they have credibility. Now, what do we pay attention to? The answer is we pay attention to ourselves. We consult ourselves. This is that individualism thing coming up again. So the expert is optional. This is different in dentistry than it is from other fields. I've looked at journalism and business and some other fields. They don't look at ethics the same way dentists do. In dentistry, the dentist is the whole game. It starts with whatever the dentist thinks is a problem in his or her own office, not what other people think might be a problem. And the dentist considers the options and weighs them and then determines whether the result has been a good one or not. Dentists also have the option of dilemmas. Dilemmas aren't popular in bioethics or ethics in general or other areas where people professionals look at ethics. A dilemma is a case where it could be one thing or it could be another and nothing is perfect, but all of them are kind of okay. You just pick the one that you think will work best for you. The Commission on Dental Accreditation made a requirement for dental schools in 1997 and it said that all the dental schools have to teach ethics. And so the young dentists are in fact a little more knowledgeable about ethics than their seniors were. But the dental school curriculum didn't say, what it said is they have to know about ethics. It didn't say they had to be ethical. So in dental schools it's probably not going to make them ethical because there's only 23 hours over the four year period on average devoted to that. And that number is going down. In fact that little graphic on the lower right shows the number of publications on dental ethics and it's less than half of what it was a decade or so ago. Now, I applaud the ADA for creating an ethics hotline. That's a situation where you could phone in to the ADA anonymously and you could get some advice from an expert on dental ethics and they would tell you about what the code said. We don't do it anymore. We stopped doing that. And one of the reasons was that they weren't phoning in with ethical problems. They were phoning in with questions like, can you tell me a good lawyer that I can use to get at this guy who was cheating this other guy? And also it wasn't the dentists who were phoning in. It was the patients and the staff who were phoning in. And surprising that they were disappointing that no one phoned in and said, how can I be more ethical? What can I do to be more ethical? So, is ethics an opportunity? Or is ethics an obligation? Is it something you'd be happy to do? Or something you have to do? And people who've looked at the surveys that we've done and so forth are quick to point out we never asked the dentist whether they were ethical. And that's true. We didn't. Asking a person, are you ethical is not a value question. It's an intelligence test question. Who's going to say, no, I'm not ethical. In fact, I'm probably one of the least ethical people around. This is something called response bias. And on surveys people tend to give the responses that they think others are looking for. So how did we get at whether dentists think they're ethical? Surprisingly, we used bias as the can opener. We use something called attention bias. And it's well known that people pay attention to positive things about what they like and negative things about what they don't like. So if you told me whether you watch Fox News or CNN, I'd be pretty accurate in guessing whether you voted for a man or a woman in the last presidential election. So what I did was make up fake journal article titles. They were titles like the 10 newest advances in technology or the public thinks dentists are not treating everyone fairly. So there are positive things and negative things. And they're about dentists income techniques and dentistry ethics and health outcomes. Here's what we found. Believe it or not. Income is not the major concern among dentists. Here's the second concern and other surveys have confirmed the same thing. Dentists are primarily concerned about technical quality of dentistry dentists like to do dentistry. They would feel better if they took their hands out of the patient's mouth and they looked at that and said boy, I hope the patient appreciates this crown as much as I do because that is a nice looking crown. They are concerned a little bit about money and they would be happy to get more money. That's not that's not a problem. The question now is what about ethics and they're all health of the public. That isn't so that isn't such good news. Not only are those two values lower than the other two, they're a bit negative. So dentists don't want to go and have someone tell them that they're being unethical. They don't want to read another paper that says well there's an access issue. Now the difference between the ones on the left and the ones on the right is qualitative not quantitative. Opportunities are values that can be satisfied indefinitely. More is always better. There's always room for more. Even though dentists are in top two or three percent of income earners in this country, no one is saying well I got enough, you know, no problem. The items on the right side are obligations or what we call motivation factors and that means there's a standard. You'll be up to standard or people will start paying too much attention to you. But if you meet the standard you don't get extra credit for going beyond the standard. So here's the summary. Practice centered ethics based professional service firms model is being threatened by forces outside of the profession. Now let me stop for a second. I'm not going to talk like I'm an ethicist or something. I'm not going to talk about Dave Chambers. I think that's terrible. Personally, I believe the professional service from model is wonderful in terms of dentistry. It's what dentistry should be based on. It's what dentists. It's what made dentistry a profession that serves the public. Well, I'm worried that other people are taking a chip and a whack at it. Okay, now I'm back to the to the person presenting the presentation. The extent to which the profession is honoring the implied contract to police itself is at this point an open question. Organizations are now competing to offer to dentists services. And they're retreating from offering dentists help with their professional identity. It is increasingly being seen as situational bargaining rather than character. And that has some good features and it has some bad features. Dentists are still in a position to self define what it means to be ethically good enough that is still practice individually. And the public sees dentists as technicians. And the profession seems to agree that that's that's okay. Now, what about approaches ethical approaches to address some of these issues? I divide them into two categories. There's the me ethics and the we ethics. The ethics of judgment sounds like this. Here is what you should do. And the ethics of justification says, I know I'm right. On the other hand, the we ethics involves the ethics of engagement. And it says, let's see if we can figure out something here that works better for both of us better for both of us. And then the leadership ethics, which says, can I help you be more ethical? The ethics of judgment here are just a couple screenshots I grabbed from a recent ADA news. It says this, surely everybody, everything would be better if you just did what I think you should do. A problem with that is that it just won't work. Who wants to be told what to do? Who gets to do the telling? How do we resolve cases of conflict between the experts? And what usually is the the ethics of judgment is we want somebody else to do something. And we're going to use threats and power and economic persuasion, a little deception and so forth to get them to do it. But those all sound so negative. We're going to dress it up and make it sound like it's really ethical. What we're asking to do now that guy on the right is Gary Harden. And the reason he gets to be in these pictures is that he wrote probably the most famous of all essays on this problem. It's called the tragedy of the commons. And Harden says, don't count on others to solve your problem. Doing so means acting against their own best interests. I think Harden's kind of right on that. But what about the ethics of justification? This is the default position. This is what bioethics is based on. This is the principles approach. This is the codes approach. This is the dilemmas approach. It won't work. Naming the problem doesn't solve the problem. Now, when you get to the pearly gates, they're going to give you an entrance exam and you have to write up fill out this paper and so forth. The question is going to be, can you spell non-maleficence? No one's going to be denied admission because they can't spell non-maleficence. Now, do we know what is right? A lot of us know what is right, but we don't do what's right. And what about these conflicting experts? The experts, that's how we get paid as we disagree with the other experts. In French, taking a trip down the Dordogne River Valley does not make you a Frenchman. It's a poor mind that can't gen up some excuse for what it wants to do. Now, that was said by William Jennings Bryant. Actually, Bryant won this goldstile. Isn't that amazing? Okay, let's switch to the we ethics. The ethics of engagement. We can always listen to others, usually to our benefit. We should always be allowed to tell others our side of the story, usually to their benefit. Now, I'm going to read this sentence in red because it's very important. It's the whole summary of the whole presentation. We're competent, reasonably informed and uncoerced parties. That's you and your patient and your colleagues. Exchange views about how they believe the world could be made better. We could be better. There is a mutual strategy that neither party has ethical grounds for wanting to change under the circumstances. That's very important. That's my definition of ethics. That's the ethics of engagement. It's a process approach. It's how to be ethical. It's not what you think other people should do to be ethical. And the marvelous thing about it is that it requires no enforcement. If you and the insurance company agree that this is the best that both of you can do, then you won't cheat and they won't cheat. So there's no need for enforcement. Now, if that's chamber's rule for ethics and there's all these other things, chamber's corollary is all the other approaches are less ethical. Now, this picture on the right is one of my favorites. I got this bookmarked. That guy in the middle is my hero. His name is John Nash. He's dressed up really nice and the reason is that they just gave him the Nobel Prize. That's pretty neat stuff, you know? And the reason they gave him the Nobel Prize is that he proved. He didn't suggest. He didn't propose. He didn't argue. He proved that the sentence in red on this slide is always correct under all circumstances. Ethics is unavoidable and it's powerful if you really do ethics. So there's something even better. That's the ethics of leadership. And that's any person in any position who makes it possible for other people to be more ethical. It's the person who befriends another person who's confused, who doesn't know that he or she is really appreciated, but they are. This person who offers a little guidance. Did you see this report about so-and-so? This person who role models. It's the person who does the right thing and expects that a few other people will follow him. It's the person who mentors, who finds and trains up his or her replacement. It's the coach. It's the one who can't do it himself anymore but tells others how to do it. There's a great coach on the bottom right. That's John Wooden, one of the greatest coaches of all time. And John Wooden said, the main ingredient of stardom is the rest of the team. I think he's right. And this person is Nolan. This is Nolan. He's two years old. He's having a good time. But if Nolan stood up very quickly now, he might bump his head on the counter and get himself a big ouchie. Now, there's two ethical approaches being illustrated here. One of them is the me ethics. And it says, Nolan, look out. Nolan, be careful. Nolan, watch what you're doing. Or worse yet, Nolan, I told you so, Nolan. The picture on the right is we ethics. You just set it up so that Nolan is going to do well and you say, hey, Nolan, let's have a good time. So what is the new professionalism? Ethics isn't something you say. It's a syntax for how you live your life. It sounds like this. I like what you just did. Show me how. Or it sounds like this. This isn't working. Let's talk about it. It's the one minute you add to every patient encounter where you listen to the patient and then write down what they said in the chart. It's joining positive groups, your component society, the Rotary Club, church, synagogue, mosque. The book club is being around people who are talking to each other about the better world that they could work on. First, do it and then say what you've done. Now, Confucius said that. I'm not kidding. Confucius really did say that's what ethics was. Do the right thing and then say something about it. It's looking for the common good and incidentally the common good is self-reinforcing. I don't like that man. Abraham Lincoln said that. A lot of presidents have said I don't like that man. But Abraham Lincoln said something further. I think I'll have to get to knowing better. So let's see what we can find about going together. The world is changing around industry. We can't predict and we can't control what will happen. But the quality of the solutions we find will depend on who participates in that conversation and our willingness to listen. The we-ethics has the best chance of succeeding. So let me close with a little story. This story was told by a slave in Turkey, 600 BC. His name was Esap. And he talked about a crow and the crow was hopping along saying, boy, I'm thirsty. I could sure use a drink. He came across the picture and he looked in and low in the hole there was water in the bottom of the picture. So he says, you know what? I'm going to use a little me-ethics. I'm going to tip that picture over. But the trouble was if he pitched the picture over or he tipped it over, the water would run out and he wouldn't get any. So that isn't going to work. So he says, well, there's another kind of me-ethics. I got a great beak. I got one of the most fancy beaks. I'll just stick my nose down in there and get it. But his beak wasn't long enough. As an individual, he could not change the world. So he says, well, wait a minute. There was this webinar thing that the American College of Dentist did and Chambers said something about ethics of engagement. I'm going to get some of these rocks here and I'm going to stick these rocks in the picture. The more rocks the crow put in the picture, the higher the water level became and he eventually drank his fill and then shared that information with his murderer or crows or his friends. The moral to the story is very simple. Don't expect to get something out unless you put something in. It's been a privilege sharing this time with you to talk about ethics. Each of you individually is a point of light for dentistry. Together, as we engage those who are outside and don't know what's the right thing and engage those who are within the profession and don't know the right thing and work with them. The profession will rejoice. Thank you.