Ethics and business

The title of this module might seem to be something of a misnomer for those readers who do not see themselves as being in business at all.

There is a purist view that dentistry is, and should always remain, a profession and that business considerations should never be a factor under any circumstances - but this, too, is somewhat naïve and unrealistic.

Strictly speaking, the defining characteristic of a business is that it exists in order to generate profits. The ethical dimension is introduced by examining what else (such as values and principles) an individual or organization might be prepared to sacrifice in pursuit of profits.

A privately-owned dental practice is a business, whichever way you look at it. A self-employed dentist, who pays for services and facilities provided by a third party, automatically finds they are also in business. Ethical considerations still apply to dentists who work in businesses that are owned and operated by others, especially if they have any kind of managerial or supervisory role which involves implementing the business policies and processes which others have created.

Less obviously, dentists who receive any kind pf payment for professional services are also considered to be in business. This includes but is not limited to:

• Dentists who receive fees for advisory services
• Dentists who receive fees for consultancy services
• Dentists who receive fees for giving opinions
• Dentists who receive fees for providing reports
• Dentists who receive fees for lecturing and writing

Priorities

A fundamental principle of professional ethics in healthcare is that serving a patient's best interests should always take precedence over any consideration of profit or personal gain. Taken to an extreme conclusion, this suggests that a professional person would be expected to forego professional fees entirely, which would plainly be unsustainable.

Nor would it be either fair or logical, to single out the individual practitioner, or the privately-owned dental practice or clinic, for criticism over their natural wish to balance the need for solvency against the desire to provide oral health for those who want and need it.

Governments and many charitable (ie not-for-profit) foundations also operate healthcare facilities, which need to be run within agreed financial budgets. From time to time, difficult decisions - both politically and in terms of healthcare economics - need to be made, and they can impact upon:

• Who is (and is not) accepted for treatment
• The scope and extent of the treatment that can/will be offered to different groups of patients, and the criteria that will be applied to such decisions, which some may view as the 'rationing' of healthcare
• The resources allocated. This affects the availability of healthcare professionals and support staff, the quality of the facilities, equipment, instruments and materials, and the adequacy of associated services (for example, the laboratory support) provided.

These situations can generate many ethical dilemmas for clinicians in salaried employment, just as easily as for those who own and control the business themselves. Whether, as an employee, you should provide dental care at all, if you do not believe that you can do so safely and to an adequate standard, is a very significant ethical question for a professional person. We owe the same duty of care to our patients, whether we own the business or not.

The profit motive

It would clearly be unethical to knowingly compromise patient care in search of greater profitability by;

1. using materials of an unacceptable quality
2. accepting and fitting laboratory work of an unacceptable quality
3. cutting corners in compliance with standards of health and safety, especially infection control and ionizing radiation legislation
4. giving dentists - especially young and inexperienced dentists - excessive 'targets' of performance and output, thereby encouraging them to work too quickly to maintain adequate standards of care
5. employing untrained staff who are not capable of carrying out the duties assigned to them to an acceptable standard; the personal well-being of such employees may also be placed at risk if they are exposed to risks in the workplace, of which they are unaware
6. to treat patients without having made suitable professional indemnity arrangements to ensure that they can be adequately compensated for any avoidable harm they might suffer while receiving dental care and treatment

Similarly, if one's remuneration is linked in any way to the gross fees earned, as may be the case in many practices, it would be unethical to allow your clinical judgement, or a patient's best interests, to be clouded or compromised by the basis upon which you are paid.

For example is it reasonable to recall patients at intervals that are dictated by the number of unfilled future appointments in the month ahead rather than by the assessment of every individual patient's actual clinical need?

Money, fees and patients

Dentists working in general or specialist practice, where money changes hands, are much more vulnerable to dento-legal problems in several business-related areas, than their colleagues working in the public sector. It is therefore particularly important for dentists and their practice teams to handle the financial aspects of patient care with tact and sensitivity, and to adopt a professional and ethical approach at all times.

A professional person is entitled, just like anyone working in different walks of life, to be paid for their services, but one should still avoid creating the perception that money and profit is the overriding objective and that patient care is very much a secondary consideration. When discussing the nature of professionalism (Ethics module 3) we refer to the 'higher motives' of a healthcare professional and the need to make the best interests of patients our first consideration.

1. Patients have a right to know, in advance of treatment, how much their dental treatment is likely to cost. Forewarn patients if these fees might increase for any reason (for example if it is not possible to confirm a precise, definitive treatment plan at the beginning of treatment, until the prognosis of certain teeth has been established, or until you have had a chance to assess the tissue response and/or level of patient co-operation).
2. Keep the patient informed if it becomes necessary to alter the treatment plan (and hence, the fees charged) as treatment proceeds. Involve the patient actively in these decisions, which are a fundamental part of the consent process. If there are alternative treatment options, give the patient a fair and balanced explanation of what they are, and how they compare - including relative costs.
3. Never make assumptions regarding the patient's ability or willingness to pay fees. Offering only the treatment that you think the patient can afford, or compromising on treatment because you think the patient can't or won't pay for a more expensive option invites problems because the patient may later argue that they would certainly have chosen the more complex/costly option if only it had been offered to them.
4. Before chasing unpaid fees, always check that the patient is happy with any treatment that has been provided earlier. It is also sensible to check your records and x-rays, to ensure that your treatment could withstand the rigorous scrutiny of authoritative professional colleagues.
   
   Outstanding fees should only be pursued from a position of strength, because it is almost inevitable that a patient, who is unhappy with the treatment provided, will respond to any claim for unpaid fees, by making a counterclaim which alleges negligence or some kind of breach of contract on the part of the dentist.
   
   If you might be vulnerable to criticism in respect of any aspect of the treatment provided, think twice before pursuing unpaid fees. This avoids the embarrassment of having to back down at a later stage. If it becomes necessary to involve commercial debt collectors or lawyers, remember that they become an extension of your professional relationship with the patient concerned. Take reasonable steps to satisfy yourself that they are not acting unethically or inappropriately in your own interests.
5. It is important to respect a patient's dignity and privacy when dealing with the financial aspects of their treatment. Wherever possible, sensitive financial discussions should take place in private, out of the hearing of other patients. Any conversation regarding unpaid fees should not involve anyone except the patient, or someone that the patient has specifically authorised to speak on their behalf in this connection.
6. Keep meticulous records of fees quoted, charged and paid, and any discussions in relation to the financial aspects of treatment. Record also, each stage in the process of collecting fees, particularly when the patient seems reluctant to pay the amounts due. Such records should include notes of face to face conversations and telephone calls, and copies of any correspondence with the patient. These records should be kept with, but ideally separate to the patient's clinical records.

Ethical dilemmas in business decisions

When dealing with the financial aspects of patient care, many of the practical issues are inseparable from the underlying ethical considerations which underpin them in a professional healthcare environment. These ethical issues that arise in connection with financial aspects of patient can include the following:

• A patient's best interests must remain paramount at all times. Dentists should never be tempted for reasons of financial gain to recommend or provide treatment which is not in a patient's best interests.
• Dentists should take particular care to avoid money-driven compromises wherever possible, especially if such compromises would result in an unsatisfactory standard of care being provided.
• Patients should be given accurate and balanced information about treatment options and how they compare in all respects - including that of cost.
• Consent should never be obtained in bad faith – for example, by seeking to persuade a patient that a certain treatment is necessary, or in their best interests, when this is not the case.
• Dentists should not hold themselves out as being competent to carry out a certain type of treatment if this is not so; a dentist must be prepared to suggest second opinions when indicated, and should not allow financial or business considerations to persuade them into carrying out treatment which they are not trained or competent to provide to an appropriate standard.
• Patients should be informed if any details of the treatment provided for them (the materials used, for example) are not as originally proposed and agreed.
• When claiming fees from third parties (state funded healthcare schemes, health funds, insurance companies etc), dentists should take care to avoid making any claims that are inappropriate such as claims for treatment which is not provided, or which is different from that claimed).
• The public has a right to expect that dentists will behave with fairness and integrity. A patient's dignity, autonomy and rights should be respected at all times and no treatment plan should ever be motivated by greed, business advantage or financial gain to the detriment of the patient.
• In all financial dealings with patients, dentists and practice staff should treat patients as they would wish to be treated themselves.
• Every member of the dental team shares a duty to protect the patient's personal information, which include all the financial details of their treatment. Avoid discussing financial aspects of a patient's treatment with, or in the hearing of others. This also applies to both telephone and face to face discussions with another member of the patient's family. (Module 9 Confidentiality)
• Dentists should at all time adhere to professional standards of behaviour in fee charging, handling and collecting fees. The way in which dentists conduct their financial dealings with patients, either directly or through third parties, has a direct impact upon public confidence and trust in the profession.

Unacceptable business practices

Suggestions of an excessively 'commercial' or 'business-like' approach to a patient's care and treatment do not reflect well upon a healthcare professional. These allegations typically include:

• overprescribing/overtreatment
• under-treatment/supervised neglect
• claiming for treatment not provided
• overcharging
• under-charging/discounting, cutting corners and poor standards

Most of the dento-legal challenges arise from these problem areas:

1. Demanding fees for treatment which has failed, or which the patient believes to be unsatisfactory.
2. Demanding fees which are greater than the patient had been led to expect, or greater than those which the patient had agreed to, without proper explanation.
3. Charging fees at a level which the patient believes to be excessive.
4. Charging fees for treatment or services which the patient perceives (rightly or wrongly) you have not provided.
5. Charging fees for treatment which the patient perceives (rightly or wrongly) as being unnecessary.
6. Charging fees for treatment which the patient perceives (rightly or wrongly) as have been necessary only because of some deficiency in treatment which you have provided previously.

Involve every member of your practice team in avoiding problems in the financial aspects of treatment. Make sure that they understand the ethical principles involved, and give them clear ethical and professional guidelines and policies to adhere to. This is an area where the team approach to risk management pays dividends.

Buying, selling and moving practice

When you are selling or buying a practice (or an interest in a practice), you should always act honestly and in good faith. It is not simply a business 'deal', but also a transaction which involves two or more professional colleagues.

Where a payment for goodwill forms part of the selling price, it is important to remember that goodwill is no more than an opportunity to secure a future income stream, and to generate future profits from it. Nobody ever 'owns' the patients, or has a right to expect their continued attendance. It would be unethical to interfere with a patient's freedom to choose from which dentist(s) they wish to receive their care and treatment.

It is not uncommon, when dentists leave a practice, that there is a restrictive covenant (sometimes known as a 'barring out' or 'exclusion' clause) by which the departing dentist gives an undertaking not to solicit patients that he/she has treated while working at the practice in question. There may be a further agreement not to work within a specified radius of the original practice for a specified period of time.

While a reasonable provision of this nature may be desirable or even necessary to protect the business interests of a practice owner, this should not be so restrictive as to act against the public interest or to contravene any trade practice legislation eg. anti-competitive behaviour.

However, where a reasonable undertaking in this regard has been given, entered into freely by both parties, then it may be unethical, as well as being contrary to the terms of the contract (if such a contract exists) for the departing party to actively solicit the attendance of a former patient. On the other hand, it may be equally unethical for those remaining in the original practice, to actively obstruct a patient who wishes to discover the whereabouts of the departed dentist, or to give them misleading or untruthful information regarding his/her whereabouts.

Patients should not become ensnarled in a professional dispute when dentists move practice. As a general principle, patients should be free to choose from whom they wish to receive treatment and should not be allowed to attend a practice expecting to see Dentist X when in fact, everyone (except the patient) knows that they will be seeing Dentist Y because Dentist X has already left the practice.

Ideally, a departing dentist should advise patients with reasonable notice that they are leaving, and explain any arrangements that are being offered for the patient's continuing care. It does not reflect favourably upon the reputation of the profession if it is obvious from the tone of any communications that they are caught up in an unpleasant dispute between two dentists. Any disagreement should remain a private matter between the professionals concerned, every effort being made to ensure that patient care is not compromised in any way.

Marketing and business promotion

All businesses are naturally keen to promote their services. But Dental Boards and Dental Councils require any such promotional activity, advertising and canvassing to comply with local and national guidelines. In general these guidelines are designed to ensure that false or exaggerated claims are not made, and that all statements made are legal, decent, honest and truthful. In the case of a dentist, they should also conform to the locally agreed norms of professional propriety, which vary from one country to another. The usual aim is to ensure that members of the public have a fair, balanced and sufficient means of assessing the information provided to them about different potential providers of their dental care.

Dentists are expected to comply with these standards, and although practice owners are likely to bear the greater burden of responsibility for any inappropriate advertising/practice promotion, any other dentist working in the same practice also has an ethical duty to take reasonable steps to ensure that their own services are not being directly or indirectly promoted by the practice owner, in contravention of the relevant guidance.

The same applies where practice owners enter into agreements with third parties, for the referral of patients, perhaps to the exclusion of other practices nearby.

Fees should not be offered or accepted for the referral of patients. Any such fee or inducement of any kind would be unethical in being likely to compromise the professional relationship between patients and the dentist(s) involved.

Improper motives and conflicts

Dentists should never be persuaded to say or do things that they do not believe to be true, or to do things that they know to be inappropriate, in return for a fee, retainer or other consideration.

Examples of this may occur in the context of supporting or promoting commercial products, publishing research or other articles, giving lectures or making public statements which favour one point of view over another. If one has a conflict of interest, this should be clearly and openly stated in advance rather than having to defend your ethical behaviour after the event, having failed to declare such a conflict.

Summary

It is not always easy for a professional person - particularly those working in a healthcare profession such as dentistry - to strike the right balance between a caring, supportive and patient centred approach, and the need to make a living and to run a profitable business in order to achieve this.

Striving to act ethically and professionally at all times will help you to find this elusive balance, and ultimately it will be more rewarding and professionally satisfying.