Legislative Spotlight - Shahe Dishakjian ('21)

It can be said that legislation is the means by which ethics are established and enforced in liberal democratic society. Although this statement may appear to be benign and obvious upon first glance, it actually reveals something deeply troubling about the state of ethics in our world. That is, at any given time, we may be operating in a society that is incapable of operating ethically due to the absence of a law, or the presence of an ethically problematic one. If one goes back far enough in history, they are sure to find some sort of behavior that would be decried by virtually everyone in the present day. With little exception, this problematic behavior was borne out of a positive legislative failure (the presence of an immoral law) or a negative legislative failure (the absence of a law that would work to prevent said immoral behavior). Therein lies the WREB.

This article will aim to illuminate a specific way in which the WREB exam and other single-encounter patient-based competency exams fail the ethical litmus test and are likely to be remembered as a legislative failure in the annals of dental history. In order to effectively do so, we first need to explicate the ways in which ethics are approached in healthcare professions such as dentistry. For historical reasons beyond the scope of this article, the notion of ethics in healthcare has essentially been reduced to the methodology of Principlism. In this ethical approach, one need only memorize certain principles (i.e. veracity, nonmaleficence, etc) and then when confronted with an ethical dilemma, one must simply select the correct principle from their ethical swiss army knife and then “do the right thing.” The problem with this approach (which even the most ardent supporter of Principlism would admit) is that these ethical principles may be at odds with one another during a given ethical dilemma. What supporters of Principlism are less likely to admit, however, is that such an ethical approach actually provides its users no means to rank order these ethical principles in any consistent or universal way. As such, two dentists – beholden to the same set of principles, and faced with the same ethical dilemma, may come up with different solutions to a given issue. If we consider that an ethical compass must always point true north, we can see how the compass of Principlism may in fact be broken.

Fortunately, there are ethical approaches that are just as efficient as Principlism without the methodological baggage. Perhaps the most useful is the Deontological approach set forth by Kant, which may be accurately boiled down to the notion that one may never treat another human being merely as a means to an end. So how does the WREB exam fare with regard to this ethical approach? According to the 2018 ASDA Task Force Report, these exams are administered in such a way that the focus is on a single quadrant, lesion and tooth that both best meets the exam criteria for acceptance (and will not be rejected resulting in failure of the exam) and is perceived by the candidate (test-taker) to provide the highest likelihood of success. This single focus is typically in lieu of the patient’s comprehensive and most severe or urgent needs, resulting in a standard of care that may well be below today’s acceptable level. It would take a seasoned salesman to convince anyone that a single-encounter exam focused on a specific lesion in a specific quadrant in a patient’s mouth would be anything other than the treatment of that patient as merely a means to an end (in this case, ascertaining the dentist’s clinical competency). Even if we were to assume that exams like the WREB are valid and reliable, such assumptions would be trivial as the exam itself is ethically bankrupt. As healthcare practitioners, it seems paradoxical to mark the beginning of our clinical careers by passing a test that necessarily entails us carrying out ethically problematic behavior on a patient. On the bright side, history books have no page limit.