Advertising & Promotion

Is Dr. Sims’ proposed advertisement unethical? Should dentists guarantee their work, cosmetic or otherwise? Is any advertisement by a dentist unethical? Advertising by dentists has been an ethical concern since the first days of the profession, and we will examine the ethical issues of: 1) dentistry: trade or profession; 2) truth in advertising:respect for patient autonomy; and 3) false and misleading advertising.

Trade or Profession

The dialogue between Drs. Lange and Sims presents disparate views of the ethics of advertising and the practice of dentistry. Is dentistry a profession where the members act as fiduciaries for their patients, placing the patient’s best interests even before the dentist’s own self-interest? Or, is dentistry really a trade where the dental providers and consumers are primarily competitors, in the commercial sense and, therefore, subject only to the ethics of the marketplace?^1,2 Both views have been criticized for either being too ideal (professional) or too cynical (trade). These questions have endured for over a century for dentistry and since the ancient Greeks for medicine.

Dr. Lange views the proposed advertisement as “unethical” and declares, “I’ll have no part of it!” His view holds dentistry as a profession, not a trade. One distinguishing feature of a profession is a formal code of ethics. The desire to raise and maintain the status of dentists as members of a learned profession led to the first ADA Code in 1866.³ This Code dedicated a substantial segment to the question of advertising, a growing concern for the profession:

Article II., Sect. 3. “It is unprofessional to resort to public advertisements, cards, handbills, posters, or signs calling attention to peculiar styles of work, lowness of prices, special modes of operating, or to claim superiority over neighboring practitioners, to publish reports of cases, or certificates in the public prints, to go from house to house to solicit or perform operations, to circulate or recommend nostrums, or to perform any other similar acts.” ⁴

Dr. Sims views the care of patients as we might view any commercial concern, in essence a trade. Eyewear companies, Sims argues, guarantee their products, so why should dentists be any different? A consumer may view dentists as providing products, such as dentures or “plates,” fixed partial dentures or “caps,” amalgam or resin restorations or “fillings,” and services like prophylaxis or “cleanings,” or bleaching discolored teeth or “whitening.” Consumers today expect guarantees for products such as toasters and watches, and services such as pest control and lawn care. A three-year guarantee for dental products or services is consistent with Dr. Sims’ view of dentistry.

The FTC challenged medicine and dentistry on this very question of profession or trade. The FTC brought legal action against these professions for restricting its members from advertising and soliciting patients, and for interfering with contractual relations with other entities, such as paid group plans, HMOs and nonprofessional groups. In March, 1979, the out-of-court settlement by the ADA and the FTC included these provisions: 1) The ADA agrees not to restrict truthful advertising; 2) the ADA may prohibit “false and misleading advertising;” and 3) there is no admission by the ADA that any law has been violated.⁵ The physician David Schiedermayer observes that these FTC rulings signaled that medicine and dentistry are now regarded primarily as a trade and that the subsequent codes of ethics must abandon any pretense of a professional ethic for a business ethic¹.

The current ADA Code states:

“Although any dentist may advertise, no dentist shall advertise or solicit patients in any form of communication in a manner that is false or misleading in any material respect.” ⁶

The TDA Code of Ethics addresses the question of trade or profession in the following manner:

“The dental profession’s privilege and responsibility of self-governance demands ethical standards more stringent than those of the marketplace. These standards include exercising honesty and restraint when making statements or representations about care and skill, both in private discussions with patients and in public announcements.” ⁷

The TDA Code emphasizes that the profession’s ethical standards must be more stringent than those of the marketplace. What role do honesty and truthfulness play in the relationship of doctors and patients?

Truth in Advertising/Respect for Patient Autonomy

Patients rely on their doctors to be truthful with them. Only in the rare situation when the patient is a doctor, with similar training and experience, would the patient not have to be fully informed about treatment recommendations and alternatives and their associated risks and benefits. While health care professionals recognize that patients cannot understand, comprehend or appreciate all of the nuances of existing conditions and treatment recommendations, their respect for patient autonomy compels them to treat the patient as a competent, moral being.

The hazard, then, of dental advertising is that dentists could exploit the fears, hopes, pain, and desires of the consumer in order to attract patients. Claims of superior service, unique therapies, promises, or special costs could deceive the patient and cause false expectations. Not all patients are equipped to be reasonable and discerning about advertisements. The philosopher David Ozar described three potential audiences for advertising: the hardened, the wholly receptive, and the reflective consumer.⁸ The hardened consumer doubts the validity of any advertising claims while the wholly receptive consumer accepts these claims as the truth. Somewhere in between is the reflective consumer, who carefully weighs the merits of the advertisements and makes comparisons and reasoned choices. What the ethical dentist must consider, according to Ozar, is what is communicated in an advertisement to the least discerning audience – the wholly receptive consumer.

Advertising claims that are false or misleading violate the respect for patient autonomy and are unethical. Are the claims made in Dr. Sims’ advertisement unethical?

False and Misleading Advertisements

Dr. Sims’ advertisement, “We specialize in making your smile beautiful” contains two messages that are morally suspect.

First, the wholly receptive consumer may interpret the term “specialize” to imply that the doctors have specialty training and certification. Since esthetic dentistry is not a recognized specialty, this statement may convey a false message of superiority over other clinicians with similar training. Secondly, the phrase, “making your smile beautiful” may mislead or deceive because there is no single description, interpretation, or universal standard for a beautiful smile. The subjective nature of esthetics may cause ordinary patients to have an unrealistic expectation from this exaggerated claim. Is it possible to make all smiles “beautiful,” and, if so, by what standard?

The second message, “All treatment is guaranteed for three years” is even more morally troublesome. Does “all treatment” involve care associated with only the “beautiful smile” or all of the care provided by the general dentists? Key information is missing in this phrase. Also, what is included in the guarantee? Will the guarantee include absolute satisfaction, 90 percent, or 51 percent? Does the guarantee imply absolutely painless care? Simply replacing a defective toaster may cause an inconvenience for the purchaser. For the patient however, care that fails to cure or to improve the patient’s symptoms affects the life of the patient. Dentists are advised not to guarantee their treatment for the same reasons surrounding the trade-versus-profession issue, and because it promises that which seldom can be kept.⁹

Is this advertisement false or misleading in a material respect? A piece of misleading information in an advertisement is material if it makes a difference in the mind of the perceiver. Therefore, a false or misleading statement in advertising is material if it causes the consumer, called the “reasonable” consumer, to purchase this product over its competitors, or buy a product that the consumer would not ordinarily purchase.¹⁰ Dr. Sims’ proposed advertisement is unethical because it may mislead the consumer into believing that the dentists are specialists who can make all smiles beautiful along with the guarantee of successful treatment outcomes.

Each advertisement needs to be analyzed on what it implies along with what it says and measured against state statutes governing dental practice.^11,12 Dr. Sims would be advised to consult with an attorney about this and future advertisements.

Conclusion

The moral dimension of health care requires us to consider the unique nature of each of our patients. Uncertainty is inseparable from the provision of care; there are no absolute or simple predictions about the outcome of care. Advertisements that guarantee successful treatment outcomes are foolish and unethical, warp the fiduciary nature of the doctor­-patient relationship, and threaten the integrity of the profession. Trade or profession? You decide.

References

1. Schiedermayer DL. The process of deprofessionalization: Getting down to business in dentistry: the effect of advertising on a profession. J Am Coll Dent 1988;55(1):10-6.
2. Profession and professional obligation. In: Ozar DT, Sokol DJ, eds. Dental ethics at chairside: professional principles and practical applications. St Louis; Mosby, 1994:12- 7.
3. Romans M. Advertising in dentistry. Bull Hist Dent 1972;20(1): 16-24.
4. Code of dental ethics. Trans Am Dent Assoc 1866:404.
5. Legislation & litigation: From the Federal Trade Commission, the final order on ethical restrictions against advertising by dentists. J Am Dent Assoc 1979;99(5):927-929.
6. 5-A Advertising. ADA Principle s of Ethics and Code of Professional Conduct. January 199 5:8.
7. Principles of ethics and code of professional conduct. Texas Dental Association May 1985.
8. Ozar DT. Professional ethics and dental advertising. Calif Dent Assoc J 1994;22 (10):27-9.
9. Schierton LS, Boerschinger TH. Advertising. In: Weinstein BD, ed. Dental Ethics. Philadelphia; Lea & Febiger, 1993:159-60.
10. Banja JD. Deception in advertising and marketing: ethical applications in rehabilitation. Arch Phys Med Rehabil 1994;75(9): 1016-8.
11. Article 4548f. Unlawful advertising. Texas Dental Practice Act. Revised 7-95:9-11.
12. §109.204 Definition of false and misleading advertising. Rules of the Texas State Board of Dental Examiners Rev. 2-94:52-3.