Healthcare ethics has a gap...
Cross post from the Uehiro Centre blog.
Last month, the Guardian reported on a healthcare crisis in the country. If you live in the UK, you may have already had an inkling of this crisis from personal experience. But if you don’t live here, and particularly if you are professionally involved in philosophical ethics, see if you can guess: what is the latest crisis to engulf the publicly funded National Health Service (NHS)?
To be fair, that’s not an easy guess to make. As with many healthcare services, the NHS has suffered from overload and professional burnout—partly due to the pandemic, but not helped by other issues such as treatment of staff—in a number of areas. But it would be interesting to see how many of you guessed that the crisis was in provision of NHS dentistry.
The crisis has been building for some time. In 2020, a survey found that 77% of dentists who provided mostly NHS-funded care (dentists and dental surgeries can offer both private and NHS care, and place limits on the number of NHS patients they accept) didn’t anticipate being in the service by 2024, and around half of those planned to move into private practice.
In theory, everyone in the UK is entitled to NHS dental care, which is free for some users, and significantly cheaper than private care for the rest. But the Association of Dental Groups (ADG) found that in England, only around a third of adults, and half of children, had access to NHS care. While anecdote has limited use, I can count myself in the majority here: despite a year of searching, and ringing or emailing around a dozen practices, I have been unable to find an NHS dentist where I live.
The ADG report describes dentistry as “the forgotten healthcare service”. While in context this refers to government focus, it might also be applied to practical ethics by philosophers. An unscientific survey of major practical ethics journals* finds that while most have articles which mention dentistry, this is often only in passing, or by way of an example to illustrate a broader claim. Focusing (again, with limitations to the accuracy of my methods) on articles that appear to predominantly address ethical or political questions in dentistry, several journals had no articles whatsoever, while the most articles appearing in Medicine, Health Care and Philosophy (6), Bioethics, and the Journal of Medical Ethics (5 each).
This is not to chastise my colleagues—this is the first time I’ve ever written about dentistry, and let he who is without sin cast the first stone—but to wonder why those of us who write about healthcare don’t think explicitly about dentistry more. One reason, I assume, is that many of the issues that arise in dentistry also arise in healthcare more broadly; since dental care is just one small section of healthcare, it gets used just as one example among many. Indeed, one might ask why we should give explicit attention to just one service.
But dentistry is separated from general healthcare (certainly in the UK, and my impression is in other countries too) in a way that most other non-specialist services are not. And it is important. When people struggle to get dental services that are free at the point of use, or significantly cheaper than private rates, one of two things happen. Those who can afford it, like me, grudgingly go private. Those who can’t afford it are either subjected to long waits, or stop seeking help except when (or even despite) facing an emergency. Access to dental care is important. Oral health can be a source of significant stigma, reducing individuals’ ability to function in key social contexts. And dental problems left untreated can lead to serious pain and inability to easily perform basic functions such as eating If practical ethicists think we have something to say about health justice in general, shouldn’t we also have something to say about dental justice? Moreover, even if the same broad issues crop up in dental ethics as in general medical ethics, we know that context and specificity matters. For instance, dentistry may be unusually prone to eliding the difference between clinically necessary interventions, and those with a more cosmetic purpose.
Dental ethics and justice is being discussed—a quick Google Scholar search turns up around 3,500 hits—but it does not seem to be discussed all that much by philosophers. That should change.
An occasionally updated blog, for ideas that aren't publishable (yet).