Dentists as Public Servants
"The Fallacy and Danger of 'Public Service' "
Copyright Salvatore J. Durante, DDS, FAGD, 1989. Printed in Journal of Dental Practice Administration, Oct.-Dec. 1989. Reprinted in Texas Dental Journal, September 1990, and GP: The Official Journal of the New York State Academy of General Dentistry, March 1991.
"[P]hysicians will never again be able to set their own prices and practice without outside restraints. Medicine is now a regulated industry, and HCFA, and others, are the regulators. Doctors who are upset by this kind of change will in the future become even more upset..."[Reference 1] So says William Roper, M.D., former head of the government's Health Care Financing Administration. Such a statement would have been impossible only ten years ago, but, in the 1980's, the brazenness of politicians and government bureaucrats has reached alarming levels. In contrast, professional organizations have become more accommodating, less vocal and less confident in their defense of a doctor's autonomy. It is almost as if doctors have accepted the constant barrage of governmental interference as an unquestionable fact of nature.
In fact, some doctors directly aid the government as it seizes control of one aspect of a doctor's practice after another. For example, Physicians for a National Health Program, a fringe group representing less than half of one-percent of all practicing physicians in the United States of America, recently announced its plan for a comprehensive national health program. Under this plan all payments for health care would come from a single source: the federal government. As a direct consequence of this fact, the plan calls for drastic measures, including the following: doctors' groups would have to negotiate fee schedules with the government and all doctors would be required to accept those fees as full payment; the government would cap the total reimbursement of individual doctors; entrepreneurial incentives would be minimized or eliminated; and new for-profit investment in health-care facilities would be outlawed, gradually making the government the only provider.
There are, however, consequences that these physicians do not emphasize or even mention, but that have invariably followed in countries with national health plans, such as England and Canada.[2, 3, 4, 5] All services would be rationed by the government: patients would have to petition politicians for their health care. Medical progress, for the most part, would become a thing of the past as innovators redirected their efforts to less regulated fields of endeavor. Those doctors who chose to remain in health care would have to resort periodically to slow-downs and strikes. This is where the once-proud and independent entrepreneur of American health care, the doctor, is headed.
What were the responses of respected professional leaders to the plan presented by Physicians for a National Health Program? The New England Journal of Medicine hailed the concept of "a comprehensive plan" as an idea whose "time has come." The American Medical Association feebly labeled the idea "inappropriate," but admitted that the Association does support the principle of "universal access." [6, 7] (The AMA fails to state explicitly what it believes the government should force doctors and patients to do in order to achieve equality, or "universal access.")
If a "comprehensive plan" consumes medicine in the United States, there can be no doubt that dentists will be affected. The PNHP proposal, which is based on Canada's comprehensive plan, calls for the inclusion of dental care. Furthermore, the American Dental Association is on record as supporting the inclusion of dental benefits if a national health-care program is adopted in the United States. Unfortunately, there is a widespread belief among dental leaders that if organized medicine considers slavery through national health care an honor for physicians, then it should be good enough for dentists. (Why "slavery" is the correct term will be shown on the following pages.)
Doctors who value their independence and want less regulation of their lives realize that health care is in a sorry political state. Many physicians who sense that something is terribly wrong with the way they are treated today, and fear what is coming, are simply leaving the profession. Others do the best they can against bureaucrats armed with a seemingly endless supply of government edicts. But many, if not most, doctors are uncomfortable challenging politicians and bureaucrats, who claim to speak for "The Public." They believe that it would be unprofessional, inappropriate and perhaps immoral to assert their interests as doctors too strongly.
What has led to the present situation? Why have physicians been unable or unwilling to defend themselves effectively against an encroaching government? Why are they unable to reject a call for "comprehensive health care" despite the evidence of its catastrophic effects elsewhere? What shared ideas guarantee that dentists would make the same political mistakes that physicians have?
As we will see, doctors are steadily losing control of their lives because they have accepted the notion that they are "public servants." In the following pages we will examine the meaning and consequences of the public service principle; why it is a fallacy; and, most importantly, how we must proceed if we are to reverse the destructive government take-over of health care.
The Meaning of "Public Service"
Few doctors would object to being labeled "public servants." Many even claim the label as a badge of virtue. Yet, their confusion about precisely what this label means is largely responsible for the ongoing political suicide of the medical and dental professions.
"Serving the public" can have two very different meanings. In a non-literal sense, doctors do serve members of the public. We provide a specific service to those who want it, on mutually acceptable terms, in exchange for others' services, goods, or money. We offer a highly valued service, but we are still, in essence, traders--like anyone else in a free society. This is what we may refer to as the harmless, voluntary meaning of public service.
In such dealings between people who act as traders, no one's natural rights are violated. By "natural rights" I mean only the legal sanction to pursue one's life and happiness by acting on one's own voluntary choice, so long as one does not interfere with another's equal right to do the same. In the voluntary meaning of public service no one is forced to deal with anyone he would rather not deal with; each party in the transaction may deal with the other or not, as he sees fit. A trade is made only if each party receives something that he values more than what he is offering in exchange. In this sense, the term "public service" is harmless, but also useless. The term equally could apply to hairdressers, waiters, airline pilots, librarians, garage mechanics--to anyone engaged in economic activity in a free society.
However, "public service" also has a literal denotation, which is very different from voluntarily offering members of the public a service. The word "serve" derives from the Latin servire, meaning "to be a slave." It denotes a relationship between a master and a slave in which the master is legally permitted to use force in controlling the slave, or servant, who must dutifully obey the commands of the master. The servant is permitted to act with the permission of his overseer, but he ultimately has no right to his own life and the pursuit of his own happiness. Rather, he is granted privileges at the master's discretion. By extension, a public servant has no right to his own life, and he is obliged to dutifully obey "The Public"--or its spokesmen, the politicians. This is what I will call the public service principle. This involuntary meaning of "public servant" should never be applied to anyone in a free society.
What do organized medicine and dentistry say about public service?
A. "The dentist's primary professional obligation shall be service to the public." (American Dental Association Principles of Ethics and Code of Professional Conduct) 
B. "A dentist has the general obligation to provide care to those in need." (Ibid.) 
C. "... we ought to be careful about how we represent our profession... we have to let the public know that dentistry has never stopped being a caring institution which places our patients' needs and best interests at the forefront of all of our actions." (Editor of a dental publication)
D. "A pregnant physician has an obligation to treat patients infected with HIV. The justification for limiting her risk of HIV infection ... is not concern for her health, family plans, or career ..." (Medical ethicist at Harvard)
E. "I respect the many outstanding physicians ... and each of you for your selfless commitment in working on behalf of the health of the American people ... we are not here to do battle with the government for our self-interests ... we are here for one reason, and that is to take care of sick people ..." (1987 President of the American Medical Association)
F. "Dentists and physicians have chosen to 'enter a moral practice' and have committed themselves to caring for other people. Dentists aren't like businessmen who can restrict their practices. 'Those of us in the caring professions have an obligation derived from the fact that in assuming our occupation, we basically have committed ourselves to help. We have not primarily committed ourselves to making money, or to any other ideal, but to caring for other people. That's what it means to be a physician and a dentist. The commitment to care for people comes first.' " (News article quoting the same Harvard ethicist as quoted in D above)
In all these quotes, "public service," whether advocated explicitly or implied, is meant to be understood in the literal, involuntary sense. In fact, the Harvard ethicist (in quote F) actually distinguishes between those who live as traders and doctors, who should not. He and the others contend that some members of society may specify what they require in exchange for the goods and services that they trade, but doctors are to offer their services selflessly. In short, doctors are to view themselves, and to be viewed, primarily and literally as public servants who take pride in sacrificing their own desires, goals and lives when so ordered by "The Public."
In 1965, the doctor's role as a public servant who must provide for the public's "right to health care" was firmly established. That year, Congress enacted Medicare and Medicaid legislation. At the time many doctors fought the proposed legislation, warning that government funding and the necessary control of the professions that would follow would result in higher costs and a lower standard of care for everyone. 
Others pointed out that providing health care to any segment of the population as a matter of "right" would inevitably lead to total government control of the profession. This is true, because unlike natural rights, which sanction an individual's own effort and action in support of his life, a fictitious "right" such as the "right to health care" represents a congenital claim on the work provided by others. And since our government defends its citizens' recognized rights, it must see to it that those who owe a service to others as a matter of right, do in fact provide the service. In short, if people have a "right" to a doctor's labor, then that policy must eventually lead to governmental enslavement of doctors.
However, such economic and political arguments, though correct, had little persuasive effect, because organized medicine refused to defend itself against the charge that doctors would be shirking their moral responsibility to society by opposing Medicare. Doctors were accused of trying to place their own self-interest, their desire to be free, above the public's need for their services; they were denounced as greedy. Given their professed self-image as selfless servants of the people, doctors had to capitulate. They could argue about the details of pending Medicare legislation; but having accepted their would-be enslaver's fundamental point--that doctors have an obligation to "society" as selfless public servants--they could not argue for the absolute right of doctors to pursue their lives and form associations with their patients on an individual basis, free from government interference. They were reduced to compromising and pleading for input into the developing programs.
The last 24 years have seen a series of replays of this initial confrontation between the servants, doctors, and the master, the so-called public. As Medicare was expanded, government interference spread. Further demands from the public prompted politicians and bureaucrats to seize more and more control of doctors' lives.[15, 16] Doctors were unable to stop the process. When Medicare legislation caused prices to spiral, hospitals and doctors could not refuse to submit to the government's price-fixing schemes. Likewise, when the FDA told doctors that they could only use approved drugs for approved purposes, or when the FTC or OSHA issued their edicts, doctors were disarmed by their misguided sense of social duty.
Today, doctors must answer to an increasing multitude of governmental agencies and bureaucrats--many that directly influence treatment decisions. But because both sides agree on the fundamental nature of the doctor/public relationship and because organized health care actually embraces the idea that doctors are public servants, doctors still cannot argue effectively against politicians and government bureaucrats. After all, politicians speak for "The Public."
As long as the destructive public service principle is sanctioned and advocated by its own victims, the government will continue to demand more sacrifices. For example, HIV infection is considered a "handicap" and so, on the basis of one's "professional duty" to serve the public, it follows that a doctor must render treatment, even against his personal desires (see quote D above). When this question arose, the AMA and the ADA did not assert their members' constitutional rights of association and contract. They offered inconsistent, half-hearted arguments, such as the claim that a dentist's office is not a "public accommodation," and is, therefore, exempt from anti-discrimination legislation. At the same time, however, they amended their codes of ethics to include the obligation to treat AIDS patients.
As other "handicaps"--mental, physical, social, economic--are discovered, and doctors eventually are told precisely whom they must and must not treat, doctors' professional organizations presumably will attempt to appease the government by expanding their ethics codes' official lists of social obligations.
Another recent development illustrates a corollary of the public service principle: namely, that doctors, being public servants, are immoral if they act in their own interests and if they benefit by their own actions. Efforts are being made to pass federal legislation that would make it illegal for a physician to refer patients to an entity in which he has a financial concern (Ethics in Patient Referrals Act). This means that if a doctor decides that his patient requires a certain test, for example, the doctor would be forbidden to refer the patient to a facility that he owned.
It would make no difference if the doctor actually judged his own facility to be the best for this particular test or patient. It would make no difference if the patient wanted to use that facility because it was nearby or because he trusted his doctor's judgment. Why? Because, the authors of the pending legislation would maintain, a doctor's ability to earn money with the referral clouds his sense of social obligation. Legislators incorrectly argue that selfishness or the profit motive--the idea that one should be the beneficiary of one's own efforts--is incompatible with honesty and quality in health care. By this reasoning, doctors should not be paid at all. Or, at the very least, the government should dictate what services can be provided in any particular instance, and should dictate the doctor's compensation.
That sort of all-encompassing, or "comprehensive," regulation is exactly where acceptance of the public service principle is leading us. Medical economists have predicted that on our present government-guided course rationing of all health care will become necessary during the 1990's. The machinery is already being created. As of April 1, 1989, certain surgical procedures (ranging from bunionectomies to coronary artery bypass grafts) to be performed on any Medicare beneficiary must be preauthorized by the state's Professional Review Organization (PRO), or Medicare will not cover those procedures. If authorization for the procedure is denied and the physician performs the surgery, he is forbidden to bill the patient. If he does, he will be barred from Medicare participation for up to five years and subject to civil monetary penalties. The penalties apply even if the patient grants informed consent and offers to pay personally for the procedure without Medicare reimbursement.
Fixing fees and denying services to Medicare patients is only the beginning. Both the State of Oregon and Alameda County in California are developing schemes for rationing health care for the poor. They hope that their plans will serve as models for federal rationing of care for the entire middle class. There is also the recently unveiled, Congressionally sponsored Harvard-Hsiao study of physicians' fees, which portends an expansion of governmental price-fixing schemes. Very soon, the bureaucratic means for totally controlling all services, fees, providers and patients will be in place.
Other frightening developments are on the horizon. For instance, the United States Selective Service System currently is working on a plan for conscripting physicians between the ages of 20 and 44. Is there any indication that organized medicine or dentistry will even attempt to defend a doctor's right to his own life--including his 21st to 45th years? Hardly.
In short, the public service principle as applied to, and advocated by, physicians is reaching its climax. It should be clear that physicians will remain impotent unless they learn why and how they must reject the label "public servant."
What about us, dentists? The government has just recently discovered the dentist, due to HIV and hazardous waste. This is despite years of misguided efforts by organized dentistry, which has been actively seeking inclusion of dental benefits under Medicare and inclusion of dentistry in any comprehensive national health-care program. Organized dentistry firmly advocates the public service principle, as the quotes above indicate. Therefore, if politicians and bureaucrats decide to take further notice of us, we, like physicians before us, will be unable to defend ourselves against an advancing government.
Why Accept the Label "Public Servant"?
There are 2 main reasons why a doctor might accept the label "public servant."
1. Equivocation on the meaning of "service"
Some doctors understand the term in the voluntary sense described above, and innocently believe that no one in the United States of America would use the term in any literal sense. When such a doctor hears that he is a public servant, he simply translates that into "one who provides a service to members of the public" according to the trader principle, discussed above.
Those who insist on using "public servant" in this voluntary sense, rather than using the neutral "health-care professional," "health-care provider," or "doctor," should clearly define the term to avoid disastrous confusion. Many doctors, unaware of the equivocation, concede that they are "public servants," and conclude that they therefore must agree with the ideas contained in the quotes above. The value of the equivocation, to those who knowingly make use of it, is that innocent doctors will agree that they are public servants on the basis of its voluntary meaning, without realizing that the defenders of "The Public"--politicians, bureaucrats and policy makers--intend to institute the consequences of theinvoluntary meaning.
2. A Tradeoff for Privileges
Another reason for accepting the label of "public servant" is the fact that many doctors accept the public-service principle. As a consequence, doctors have come to accept the notion that they practice medicine or dentistry only as a privilege granted by their master, the government. Social duty, obligation, self-sacrifice and obedience, i.e., literal public service, are merely seen as the price for this alleged privilege.
In today's statist view, the doctor has no right to engage in his chosen career. He is permitted, through licensure, to provide health care only on certain conditions. This is the intellectual source of the repeated claim that the right to practice medicine or dentistry imposes certain duties and obligations. As a privileged group, doctors are expected to submit to the changing demands of the license issuer, who, supposedly, will make demands that are in the interest of "The Public." A dissatisfied doctor--one who is unwilling to make the required sacrifices to "The Public"--must give up his career and not complain if he dislikes the changing rules and societal demands.
This idea that an individual must obtain the government's permission before offering certain services to others reverses the relationship that an individual in a free society should have with his government. One should not live, provide for one's life, and form associations--business or personal--with other free individuals as a privilege granted by the State. As the Founding Fathers declared in the 18th century and philosopher Ayn Rand clarified in the 20th, all people have the fundamental right to their own lives, and governments should be established to protect this right, not to interfere with it.[19, 20, 21]
The right to one's own life includes the right to live and pursue one's happiness by acting on one's own voluntary choice and effort, and the right to keep the fruits of one's effort (i.e., one's property), so long as one does not violate the equal rights of others. The proper application of this principle to the doctor/patient relationship is essentially the same as in any other relationship between traders in a free society. A doctor offers a service, and a patient offers money, goods or services in exchange. A trade is made only if each party values what he is receiving more than what he is offering in the exchange.
The government properly has a role insofar as it must stand ready to defend the equal rights of the traders, in our case, doctor and patient. A simple example will illustrate the principle: If the patient pays the doctor with a check that bounces, the doctor has recourse to the government. He did not receive what the patient purported to offer in exchange for his services. The doctor was defrauded; had he known that the patient was offering a worthless piece of paper, he never would have entered into the exchange.
Likewise, the patient has the right to receive what he pays for. He pays for a specific service (not a specific result) to be rendered by someone who claims to have been trained in a specific manner. If the doctor misrepresents his training in order to enter into a trade with the patient, then he is guilty of fraud and the patient would have recourse to the government.
In order to protect patients from fraud, it might be argued, the government should certify the fact that one who uses the title "doctor" has completed a certain course of training. Under a certification system, a "doctor" would be able to produce, upon request, a certificate indicating that he had completed a certain course of training and had demonstrated a grasp of the relevant information. The patient would know what the title "doctor" signified.
Licensure: anti-fraud or anti-freedom?
The modern licensing system shares this feature with certification: its explicit goal is to protect patients from those who would misrepresent themselves. However, even without government licensing, patients would still be free to insist on some proof of a provider's training. Professional schools and private associations such as the AMA and ADA could act as certifying agencies, as they did in the nineteenth century prior to government interference.
The important point is that the certification aspect of licensure does not imply that the legal ability to provide health care is a privilege and that doctors must, in return, live according to the public service principle. Rather, this aspect of licensure simply mitigates the possibility of fraud, and thereby serves to protect a patient's legitimate right (to his own property).
Today, protecting the patient's rights is one concern of licensure, but certainly not the only one. Licensing not only certifies that the bearer has a certain minimal education, it forcibly excludes all non-licensed practitioners from the field. It thereby transforms the right to provide health care into a de factoprivilege. Today, a non-licensed practitioner is a criminal--even if his patients know all the facts and still want to be treated by him. By this feature, modern licensure focuses on the doctor's activities apart from the government's desire to protect the patient from fraud. In fact, manipulating physicians has become the main use of licensure.
For example, in 1985, the state of Massachusetts linked licensure to acceptance of Medicare assignment. In that state, and two others to date, physicians either agree to the government's arbitrary economicedicts--regardless of their technical competence--or they give up medicine as their chosen method of pursuing happiness.
If professional groups continue to maintain that providing health care is a privilege to be granted and denied by the government--and not an inalienable right--the requirements for this "privilege" will continue to be dictated by political whim.
How the tradeoff is supposed to work
Natural rights cannot be bargained for; privileges must be. Representatives of professional organizations understand this. They concede that doctors are public servants and use this as a bargaining tactic to preserve their privileges and to win the public's favor. The current battles against denturists and hygienists are timely examples.
Organized dentistry believes that it serves its members' interests by limiting competition. Furthermore, they see no danger in trying to maintain the privilege of providing certain phases of health care at the expense of other people's natural right to conduct their lives and make choices as they deem proper. And here is where the alleged value of being regarded as a public servant comes in. Dentistry's spokesmen can maintain that doctors are selfless public servants who could not possibly be suspected of having something as "evil" as a selfish motive. Organized dentistry paternally presents itself as a selfless defender of "The Public": they claim to oppose freedom for denturists, hygienists and their would-be clients for "The Public's" own good.
It is difficult to imagine that many people are fooled by such hypocritical positions. In fact, the danger is that some members of the public, especially politicians, will believe them, and force dentists to act on those righteous claims of selflessness. That is largely what happened to physicians during the last twenty-four years under Medicare. Physicians appealed and continue to appeal to the public service principle as the justification for their own existence. Today, politicians are merely collecting the "public service" and sacrifices that physicians said they were so eager and privileged to provide.
The real tradeoff
This misguided policy--defending the alleged privilege to treat patients on the grounds that one is a public servant--has resulted in the loss of the one value physicians thought they were bargaining to keep: the right to treat patients. The results would be the same for dentists. The tradeoff is not "meaningless" support of the public service principle in exchange for the privilege of providing health care. The fact is, doctors have been trading their natural right to associate with their patients in exchange for public servitude.
What we must recognize is that political privileges are established at the expense of the rights of others. The denial of the rights of a non-privileged provider, such as an independent hygienist, is the denial of rights as such. If we are to defend effectively our legitimate right to enter into associations with our patients without government interference, then we must recognize the right of others to do the same, as long as they do so in an honest, non-fraudulent manner. Only a doctor legally should be allowed to call himself a "doctor," but anyone should be allowed to offer health-care services in a non-deceptive manner.
A recent dental editorial neatly illustrates the disastrous consequences of adopting the public service principle and of confusing rights with privileges. A spokesman for organized dentistry wrote that "...as a profession we are well off financially and are perceived well by the public we serve ... We enjoy...honor...and have been given an esteemed place in our society"(italics mine). He then guiltily cited the existence of homeless people, nursing homes and the poor, and stated that we have been given a "disproportionate blessing." To assuage the guilt of success that he had tried so hard to induce, he assured readers that "there is much we all can do to repay the honor society gives us."
The implication is that doctors are a privileged group who live as they do by permission of society and the government. Furthermore, he implies that the service we provide is not worth what our patients pay us, and so we must continually try to repay a debt to "society" in general, apart from the people we actually treat. As we have seen, politicians who read and hear such statements know exactly what to do.
The Immediate Solution
If health-care professionals are to reverse the government takeover of their lives, certain steps must be taken immediately. Reversal will be much more difficult once the takeover is complete and doctors and patients have forgotten what it was they lost.
1. Doctors must entirely reject the notion that practicing medicine or dentistry is a privilege to be granted by the government. An individual has the fundamental natural right to his life and the pursuit of happiness. The pursuit of happiness includes offering health-care services, and doctors must assert this fact.
2. Those who would defend a doctor's right to pursue happiness by freely and honestly trading health-care services with patients must be consistent. It is contradictory and self-defeating to argue in defense of doctors' independence one day, and to argue against the independence of hygienists and lab technicians the next. Likewise, doctors cannot object to government regulation in their practices while urging Congress to increase the regulation of other businesses. (The ADA's recent efforts to outlaw smokeless tobacco ads is an example.) This is hypocrisy, which undermines the proper, principled defense of a doctor's right to independence.
3. Doctors must entirely reject the public service fallacy. We must refuse to be victimized as a result of having acquired our skills. A doctor goes through many, many years of excruciatingly long hours of study and training to acquire the knowledge necessary to combat disease. As a rule, he invests this time not because he thinks slavery is noble, but for selfish reasons: he loves the field and he loves the challenge of using his mind to fight disease and suffering. When an individual receives the title "doctor," it is because he has earned it; that is, he has the knowledge and skill that the title signifies. He owes no debt to "society" or to anyone else (specific financial loans excluded, of course).
Doctors must reclaim their natural right to set the terms under which they will engage in an exchange. Striving to better oneself and then offering the benefit of one's knowledge to one's patients should not turn a person into a second-class citizen who must seek the permission of the government before acting. When a doctor does provide a service to a patient, he and the patient engage in a voluntary exchange. Neither the doctor nor the patient incurs any debt to "society" that politicians can collect as a result of the transaction.
The Long-Term Solution
Today it is taken for granted that a doctor's moral worth can be gauged by his sense of social obligation and selflessness. The policies and statements of professional organizations and the words of the Harvard ethicist and others cited throughout this article make this point explicit. Professional organizations properly uphold the principles of honesty and integrity in their ethics codes, but they disastrously assume that self-sacrifice and public service are required for a moral practice. In fact, the public service fallacy is a fundamental tenet of the ethics codes of most, if not all, professional health-care organizations.
Therefore, consistently defending a doctor's right to associate freely with his patients and publicly rejecting the public service fallacy are not enough. These necessary political steps will be half-hearted and will fail unless all traces of the public service fallacy are removed from professional ethics codes.
I am happy to be able to report that I know of several doctors in both medicine and dentistry, from diverse subspecialties, working alone and in groups, who presently are working on new ethics codes that are consistent with the principle of natural rights. Such professional codes of ethics would recognize a doctor's absolute right to his own life, in contrast to the present codes that glorify self-sacrifice and self-destruction for society's "benefit." At some time in the future, organized health care may have ethics codes that doctors can live with.
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