How Dentists Can Avoid Bad Choices

Robert D. Stevenson, DDS

Everyone faces an array of decisions every day. These range from very simple choices to extremely complex ones. At one end of the spectrum, decisions require little thought; they are made almost automatically. At the other end, decisions may demand significant mental effort. The intensity of consideration does not always correlate with the seriousness of the decision.

This paper will leave the serious philosophical discussions for the philosophers. Instead, it will attempt to answer the question of how one can avoid making bad choices. Principles of ethics and professionalism will be evaluated in the context of the professional codes of ethics of dentistry. Emotional intelligence will be introduced as a skill to guide wise decisions.

Everyone makes choices that fall on various points along the spectrum. The associated consequences will also vary. Those who experience the extreme consequences tend to be the outliers. These are the individuals who often appear in the news.

Why do people make bad choices? Can one who is innately “good” make a bad decision? And once that choice is made, does the individual become innately bad?

Many years ago, a railroad mixup occurred in which a passenger car traveled from Oakland, Calif., to Newark, N.J. Much to everyone’s consternation, the baggage car did not make the same journey.

As railroad workers retraced the paths of the two cars, they discovered that a switchman in St. Louis carelessly moved a small piece of steel just three inches, then pulled a lever to uncouple the car. That small action sent the baggage car to New Orleans instead of to Newark.

In similar fashion, small decisions can derail one’s ambitions or send them far from the intended goal. Each individual’s character is the result of many small decisions: They become the product of their choices.

Consider that for a moment. The decisions an individual has made in life have led them to where they are today. At various points in their life, a dentist made decisions that led them to dental school. Once in dental school, the dentist made many different decisions that helped them complete the requirements for graduation. Poor choices may have delayed their graduation. Some decisions were made that determined where and how the dentist practices.

Although no one intends to stray as far as the baggage car did, occasionally poor choices are made that can lead one far from their intended destination. Some of those choices have minimal effects. Others are more significant and bring weighty consequences.

Most dentists will be able to avoid the epic bad choices that make the news, but no one leads a mistake-free life. While dental codes of ethics emphasize acting in the patient’s best interests, this discussion will also include unethical acts outside one’s practice.

When a dentist makes an outstandingly bad choice, it becomes public knowledge. One can easily find accounts of dentists who have overtreated patients, committed insurance fraud or made bad treatment decisions. Others were convicted of crimes ranging from substance abuse to arson.

How can a good dentist make choices that will keep them on the right track and help them avoid bad behavior? To begin with, let us look at business ethicist Chuck Gallagher’s insights.

Gallagher suggests that bad behavior comes from the confluence of need, opportunity and rationalization. He states that among fraud auditors, these are referred to as the “fraud triangle.” [1]

In a dental practice, need equates with the business pressures the dentist faces as they strive to meet production to pay bills and earn a living. But other needs may also influence a dentist to err when the opportunity arises. Gallagher remarked that “without opportunity, there is no fuel for the potential unethical fire.” [2]

Rationalization is sometimes referred to as the glue that holds unethical behaviors together. Rationalizations are the excuses one gives for their own unethical behaviors. Continued rationalization will dull one’s sense of responsibility for their own wrongful actions and facilitate additional poor choices.

Despite best intentions, there is a gap between how individuals see themselves and how they behave. This gap also suggests a need for additional ethical training and an even greater need for training in the ability to assess oneself in connection with their own ethical standards. This gap could be filled in part by regular review of the codes of ethics provided by our various professional organizations.

Ethical Considerations

When evaluating behaviors, it is often effective to bring ethics into the conversation. This provides common ground for dentists of varying backgrounds to understand one another. Without this foundation, cultural, religious and other differences may cloud the understanding. These codes were created to guide the dentist in navigating the ethical challenges that confront everyone. The dental profession has promoted ethical behavior through its codes for many years.

The California Dental Association (CDA), [3] American Dental Association (ADA), [4] American College of Dentists [5] and other dental organizations have all developed or adopted codes of ethics and professional behavior. These codes serve as guides for professional behavior for each dentist as they strive to make good decisions in practice and in life. The codes also serve as a reminder that, “The privilege of being a dentist comes with a responsibility to society and to fellow members of the profession to conduct one’s professional activities in a highly ethical manner.” [6]

The codes are “intended to heighten ethical and professional responsibility, promote ethical conduct in dentistry, advance dialogue on ethical issues and stimulate further reflection on common issues in dental practice.” [7]

The principles of ethics and the core values, along with the associated advisory opinions, form a foundation for understanding as well as an incentive for improved behavior. Remember, each dentist recommits to abiding by these principles every year as they renew their membership in organized dentistry.

Nevertheless, these codes of ethics may be considered somewhat limited in their scope, as their application is primarily directed toward service to the public, conduct in a dental office and between practitioners and promotion of dental services [88 as well as for the benefit of the patient. [9] Only Section 4 of the CDA Code, Violation of State and Federal Laws, refers to activities outside the office. [10]

The ADA Principles of Ethics and Code of Professional Conduct mentions five key ethical principles, which are reviewed below.

Autonomy is perhaps the most important ethical principle. Autonomy is understood as one’s right to self-determination: the right to make choices and to act on them. The professional codes refer to this as “patient autonomy,” but that does not eliminate the dentist’s own right to self-determination. Either way, this right is not ethically absolute.

The thoughtful dentist endeavors to respect their own autonomy through making good decisions.

The principle of nonmaleficence frequently conflicts with autonomy. The ethical dentist strives to avoid harming others. An individual’s freedom to choose should not cause harm to another individual. When making a bad choice, one may lose sight of this limitation.

Beneficence is centered on the dentist’s duty to act for the benefit of others, particularly in relation to the patient. Helping others was the reason many practicing dentists and students gave for wanting to become dentists. The obligation of beneficence outside the practice may be inferred, but it is not expressly stated. However, the obligation to do good does not end when the office doors are locked.

The principle of justice may also conflict with autonomy. Ethically stated, justice equates with fairness. The right to choose may infringe upon another’s right to be treated fairly. Choosing to practice while impaired, just like choosing to drive while impaired, is an example of a violation of justice because of the unfair harm to others that may ensue.

Veracity emphasizes one’s duty to be honest and trustworthy in one’s dealings with people. It connects closely with integrity.

Batson and Thompson stated: “It is often assumed that moral individuals want to be moral, to display moral integrity. But our research suggests that at least some individuals want to appear moral while, if possible, avoiding the cost of actually being moral. We call this motive moral hypocrisy.” [11] Their paper brings out an important point. Most people intend to behave ethically (or morally), but when faced with a difficult decision, they may not be willing to pay the price to act according to their beliefs.

The opportunity costs associated with ethical behavior may be prohibitive for some, while others find them very affordable. Why is this the case? Why do some dentists consistently make wise choices while others struggle?

Published studies help to shed some light on these questions.

Studies

In a recent study, Chambers evaluated discipline records in four states, including California. He categorized discipline according to dentist age, demographics and category of violation. He grouped violations under technical incompetence, practice management problems or personal issues. He found that violations in one category were often connected with violations in one of the other categories. [12]

Chambers reflected that “dentists ‘learn’ either good or bad habits and perfect them over time” and suggested that this comes in part as practice circumstances interact with care patterns. [13] This agrees with Gallagher’s statements referenced above.

Papadakis is known for her studies correlating behavior in medical school and discipline by state medical boards. In a review of UCSF graduates who were disciplined by the California Medical Board, she concluded that, “We have, for the first time, demonstrated that unprofessional behavior in medical school is associated with unprofessional behavior in practice.” [14]

In a follow-up study, she examined graduates from three medical schools and board discipline in 40 states. The study found that medical students who were disciplined for professionalism were three times more likely to be disciplined as practitioners by their state medical board. [15] Papadakis did not categorize infractions in her studies.

Munk evaluated 1,100 disciplinary action reports from 21 states. He categorized the dentists’ infractions as cognitive intelligencerelated, technical intelligence-related and emotional intelligence-related. In his analysis, the cognitive category was limited to organic mental conditions; the technical category included dental hand skills as well as critical thinking skills; and the emotional category included criminal violations as well as moral and ethical violations.

The focus of Munk’s study was on the emotional intelligence-related infractions. He found that multiple studies have been done on students and emotional intelligence but stated that, “No published studies have been found that attempt to correlate emotional intelligence instruction with the behavior of practicing dentists.” [16]

Munk stated further that the focus of dental education “is on developing students’ cognitive intelligence (thinking) and technical intelligence (doing), while emotional intelligence (being) receives less emphasis.” [17] This may be a key to helping good dentists avoid bad choices.

Emotional Intelligence and Ethical Behavior

Emotional intelligence was first defined as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and actions.” [18]

An emotionally intelligent individual can: 1) identify what they are feeling; 2) interpret their emotions; 3) understand how their emotions can impact others; and 4) regulate their emotions. [19] These characteristics connect well with the ethical values described earlier. It should be evident that developing these skills will enhance one’s ability to make good, ethical decisions.

Goleman identified five elements of emotional intelligence: self-awareness, self-regulation, empathy, motivation and social skill. [20] Development of these skills will augment one’s ethical abilities; weakness in one or more areas could contribute to ethical or moral lapses. Each element will be examined briefly in connection with ethical principles.

Self-awareness is closely related to veracity and autonomy because an individual must be honest with themselves and exercise their right to choose. It is a key skill in avoiding bad decisions.

D. Todd Christofferson, who was Judge John Sirica’s law clerk as the Watergate scandal unfolded, recently reflected on this: “A weak conscience, and certainly a numbed conscience, opens the doors for ‘Watergates,’ be they large or small, collective or personal — disasters that can hurt or destroy both the guilty and the innocent.” [21]

Self-awareness and conscience are often intertwined as individuals ponder decisions and particularly as they seek to avoid making bad decisions. This may also be connected to self-assessment, a vital skill in professional development. Dental students are expected to assess their personal performance in a wide range of competencies so they can improve their skills. However, less emphasis is given to personal and behavioral self-assessment in favor of assessing hand skills.

Without a sense of selfawareness, making ethical decisions would be virtually impossible.

Self-regulation is connected to justice and autonomy. It stems from being true to one’s character. Self-regulation is closely related to integrity and requires accountability. Accountability arises both internally and externally.

As dentists, there are many sources of external accountability, including peers, mentors, family members or religious leaders. Stricter providers of accountability include the dental board and government agencies that dictate professional behaviors. These external entities are frequently required to act when an individual’s self-regulation is inadequate, often with unpleasant consequences.

Of course, CDA and other professional organizations have expectations as well, and they have developed systems of accountability to assist members in self-regulation. These include peer review and codes of ethics. These may seem punitive at first glance, but their true intent is to assist members in their self-regulation and accountability to the profession, their patients, their colleagues and their community.

Self-regulation helps one to consider others and fosters good ethical decisions.

Empathy relates to many ethical principles, particularly beneficence, nonmaleficence and justice.

The codes of ethics for the ADA and CDA emphasize the importance of acting in the patient’s best interest. This requires empathy and its associated skills. For example, when a dentist decides to overtreat, to provide unnecessary treatment or even inadequate treatment, they demonstrate a lack of empathic skills.

Empathy provides a foundation for good ethical decisions as one considers the best interests of others; it may motivate the dentist to consider the effects of their actions.

Motivation is another important element of emotional intelligence. By nature, dentists tend to have strong intrinsic motivation. Nearly all dentists have the innate desire to excel professionally. Extrinsic factors also motivate dentists as they pursue financial and other goals.

These motivations sometimes conflict with ethical principles and concepts. For example, when the motivation to pay one’s student loans, business loans or other debt conflicts with the commitment to act in the patient’s best interests. These are thorny ethical issues and require serious consideration by the dentist who endeavors to be ethical. Balancing one’s motivations can be a daunting task. A system of accountability helps to maintain motivations within ethical and legal limits.

A strong support system may be necessary to meet these challenges.

Social skill is the final element in emotional intelligence. Social skill enables the individual to put his emotional intelligence into practice.

Dentistry has long been a solo profession, and professional social networks in the current generation of practicing dentists may be weak.

In social settings, including conversations with patients, dentists can practice their emotional skills and strengthen their emotional intelligence. Social interactions can assist in developing self-regulation and empathy. Connections with the right people can increase motivation and help provide a balance. And being with peers will certainly increase one’s self-awareness.

Social settings can help dentists strengthen their resolve to act ethically.

Emotional intelligence empowers people to use their emotions as a point of reference rather than as a basis for a decision. This can be a vital skill as one strives to make better decisions, particularly under stress. Support for the concept also comes from others.

Côté commented, “People often make decisions that are influenced by emotions that have nothing to do with the decisions they are making … People who are emotionally intelligent don’t remove all emotions from their decision-making. They remove emotions that have nothing to do with the decision.” [22] Developing and exercising emotional intelligence may help dentists avoid bad decisions.

Reviewing the disciplinary actions studied by Chambers and by Munk suggest that nearly all the bad actions that led to discipline might have involved a high-emotion situation. It follows that having a mechanism for dealing with choices that arise when a dentist is in a state of high emotion could effectively preclude many of the bad actions.

Sometimes, the dentist does not have time to evaluate their choices or desired outcomes. They must act quickly. These decisions occur frequently in practice; they may also occur outside the practice and have distressing outcomes.

The dentist with a high emotional quotient will often make decisions proactively. For example, an early decision to avoid dishonest business practices or to avoid driving while intoxicated can make choices easier during crunch time. An emotionally intelligent individual is more likely to recognize when to call on those proactive decisions.

Since its introduction, emotional intelligence has gained support, although some consider it a pop psychology fad. Nevertheless, the elements of emotional intelligence complement ethical principles and deserve serious consideration.

Applications

More studies are needed to demonstrate the value of emotional intelligence in enhancing the ethical and professional behavior of dentists.

Nevertheless, the problem of good dentists making bad choices remains. The question “Why?” remains largely unanswered. The focus has been largely on damage control and not on prevention. For some dentists, it seems simpler to prevent caries than to prevent bad behavior.

In conclusion, it seems appropriate to ask two final questions:

■ How can bad decisions and bad actions be avoided?

■ Is it feasible to help others avoid bad decisions and bad actions?

Avoiding bad actions is the work of a lifetime. The question suggests the need for preventive measures. Dentists are trained not only to manage medical emergencies in their offices, but also to recognize and prevent them. They all have an emergency kit to assist patients in this important responsibility.

It may be much easier to recognize the onset of a hypoglycemic episode than to recognize an approaching bad decision. A proactive preventive approach should be utilized, in which the dentist focuses on their guiding principles and determines ahead of time to act on them. Decisions based on one’s identified core values will help to maintain one’s values and integrity. This is an integral part of self-awareness.

Bernard Knight, who served as acting general counsel of the U.S. Treasury at the height of the financial crisis earlier this century, said, “Core values are key to avoiding ethical violations. This is because most ethics violations are not intentional. They occur because decisions are being made based on the wrong values or on emotion.” [23] He also warned that, “In the moment, we can all rationalize behavior that on reflection was inappropriate.” [24]

Dentistry’s professional codes of ethics are an important tool for the dentist who wishes to make good decisions consistently. A strong emotional intelligence will add significantly to the value of the codes of ethics.

The second question also deserves additional study. Is it feasible to help others avoid bad decisions? And at what cost? Many dentists are professionally isolated. They practice alone and may not have significant social contact with their colleagues.

Chambers opines that, “It may be unsound for the leadership of organized dentistry to shun the small number of unprofessional practitioners,” but he also feels that “the reputation of dentistry … cannot be controlled by the profession at a national level.” [25]

This hints that perhaps improving social skills through personal connection is the most effective means of managing and preventing bad actions. A proactive involvement among colleagues locally may be the best means of prevention. Peer pressure or peer support among friends can become very motivational. Renewed focus on an individual’s personal values and commitments is the foundation.

A common view that colleagues are now competitors can be a complicating factor. Sometimes this creates a wariness that makes personal outreach more difficult. This ties in with Batson and Thompson’s comments on moral integrity [26] and the difficulties in managing opportunity costs. Is it possible for an individual to help another in paying the opportunity costs to act ethically?

Chambers concludes that, “Dentists are human. In any population there will be a range from the outstanding to those who are having difficulty leading the kinds of lives to which we all aspire. … The profession has more conspicuously engaged indirectly with this issue at the policy level than through direct action by individual dentists being proactively involved with their colleagues or by reporting unprofessional behavior. This is an issue for the entire profession, working with others.” [27'

This is a challenge to each dental professional, both to act in the interest of our colleagues and to accept mentoring and advice that they may provide. Neither comes easily.

If the leaders in the dental profession accept Chambers’ conclusions, then the ethical focus of the dental profession should emphasize education and prevention over enforcement and punitive measures for those who fall short of the ethical ideal. This approach may require more effort than current methods, but it has the potential to yield positive results. Further study and discussion are needed on this concept.

There is evidence that incorporating the principles of emotional intelligence into dental education and into the professional canon may have a positive effect on dentists’ decisions. Again, further study is indicated to confirm this.

Effective self-assessment of one’s behavior and accepting accountability for one’s choices will help to create respect for the dental profession and lead to increased personal and professional satisfaction. Better decisions will likely follow this increased satisfaction.

William J. Gies advised: “Follow impulses and leaderships that represent ideals; that point the way to your professional destiny; that express integrity, fidelity, service and lofty purposes — the finest that is in you individually and professionally!” [28]

If we do this as a profession, and stay on the right track, perhaps we can do no better.

REFERENCES

1. Gallagher C. When Ethics Fail: How Good People Make Unethical Decisions. stopdoingnothing. com/being-a-leader/ethics-fail-good-peopleunethical-decisions. Accessed Aug. 22, 2019.

2. Ibid.

3. CDA Code of Ethics. Sacramento, Calif.: California Dental Association; 2018.

4. Principles of Ethics and Code of Professional Conduct. Chicago: American Dental Association; 2018.

5. Ethics Handbook for Dentists. Gaithersburg, Md.: American College of Dentists; 2018.

6. CDA Code of Ethics. Sacramento, Calif.: California Dental Association; 2018:5.

7. Ethics Handbook for Dentists. Gaithersburg, Md.: American College of Dentists; 2018:ii.

8. CDA Code of Ethics. Introduction. Sacramento, Calif.: California Dental Association; 2018:1.

9. Principles of Ethics and Code of Professional Conduct. Preamble. Chicago: American Dental Association; 2018:3–4.

10. CDA Code of Ethics. Section 4. Sacramento, Calif.: California Dental Association; 2018:3.

11. Batson CD, Thompson ER. Why don’t moral people act morally? Motivational considerations. Curr Dir Psychol Sci 2001 Apr;10(2):54–57. doi.org/10.1111/1467-8721.00114.

12. Chambers DW. Disciplined dental licenses: An empirical study. J Am Coll Dent 2018; 85(2):30–39.

13. Ibid.

14. Papadakis MA, et al. Unprofessional Behavior in Medical School Is Associated With Subsequent Disciplinary Action by a State Medical Board. Acad Med 2004 Mar;79(3):244–9. doi: 10.1097/00001888-200403000-00011 .

15. Papadakis MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005 Dec;353(25):2673–2682. doi: 10.1056/NEJMsa052596.

16. Munk LK. Implications of state dental board disciplinary actions for teaching dental students about emotional intelligence. J Dent Educ 2016 Jan;80(2):14–22.

17. Ibid.

18. Salovey, P, Mayer JD. Emotional intelligence. Imagin Cogn Pers 1990; 9:185–211 . doi. org/10.2190/DUGG-P24E-52WK-6CDG.

19. Cherry K. Habits of Emotionally Intelligent People. 2020. www.verywellmind.com/the-7-habits-of-emotionallyintelligent-people-2795431 . Accessed Feb. 20, 2020.

20. Goleman D. Emotional Intelligence 10th ed. New York: Bantam Books; 2005.

21. Christofferson DT. Reflections on Watergate. Deseret News June 15, 2017. Accessed July 1, 2017.

22. Côté S. Higher emotional intelligence leads to better decision-making. www.sciencedaily. com/releases/2013/11/131119153027. htm. Accessed Jan. 29, 2020.

23. Knight B. 6 core values and 5 emotional intelligence skills leading to sound ethical decisions. www.ipwatchdog.com/2017/07/05/6-corevalues-5-emotional-intelligence-skills-sound-ethicaldecisions/id=85213. Accessed Jan. 27, 2020.

24. Ibid.

25. Chambers DW. Disciplined Dental Licenses: An Empirical Study. J Am Coll Dent 2018; 85(2):30–39.

26. Batson CD, Thompson ER. Op. cit.

27. Ibid.

28. Gies WJ. Ethics Handbook for Dentists. Gaithersburg, Md.: American College of Dentists; 2018.

THE AUTHOR, Robert D. Stevenson, DDS, can be reached at rstevenson@westernu.edu.

AUTHOR Robert D. Stevenson, DDS, practiced general dentistry in the Inland Empire area. He is an assistant professor at the Western University College of Dental Medicine and is responsible for ethics and jurisprudence education. Dr. Stevenson also served on the CDA Judicial Council. Conflict of Interest Disclosure: None reported.