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*****
Islay McLeod’s Scotland
Children at play, Monifieth, Angus, 7.00pm, Saturday 18 September
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White fang
Robin Downie
‘White Fang’ is the title of a famous American novel written at the beginning of the 20th century, concerning the domestication of a wolf-dog hybrid. My concern is not with this novel but with the teeth one can see around gleaming from the mouths of one’s friends, as brilliantly white as those of White Fang.
Glasgow is not noted for its dental hygiene, but (as we all know) even Glasgow’s Miles Better. But the white radiance of the smile can be grotesque. For example, on the few frightening occasions when Gordon Brown smiled the brilliance of the teeth was at odds with the dour demeanour. On teeth at least, and unfortunately, he must have taken Tony Blair’s advice. Such is the demand by young and old for tooth whitening that there is concern among dentists. Or at least I assume that that was why I was asked on several occasions in the last few years to speak at dental conferences on the ethics of aesthetics in dentistry. On the surface this is an arcane topic but if opened wide it reveals an amalgam of problems not only in dentistry but also in other health-care professions.
Let us imagine that a patient asks his (as commonly as her) dentist to whiten his/her teeth, or even (much more expensively) to provide tooth implants, on the grounds that these will be more aesthetically pleasing. The dentist thinks otherwise – that the proposed treatment will be at odds with the skin colour, age and other aspects of the patient’s face. At this point someone is bound to say, ‘Beauty is in the eye of the beholder’.
This slogan is less an assertion of a philosophical position than a discouragement from further discussion.
Such discouragement is over-pessimistic – we can all recognise a beautiful face, and such appreciation is cross-cultural and applies to young and old. As the poet John Donne says: ‘No spring, nor summer beauty hath such grace/ As I have seen in one autumnal face’. Beauty, as distinct from sexual attractiveness (‘I can’t resist the way your nose turns up!’), has to do with balance and proportion and a general overall coherence of shape and colour. Suppose then that the patient is middle-aged. Teeth in middle-age tend to be a bit off-white and gleaming white gnashers in the middle-aged look incongruous, or as if the teeth are false.
To show I am not politically biased consider John Major. He has quite a decent shape of face but when he smiles his over-white teeth just don’t fit – they make him seem fake. Now, suppose that, despite the dentist’s advice that white implants are a bad idea, the patient persists and says ‘The decision is up to me’. Or, to take a more extreme case, suppose that the proposed treatment may be harmful. (Sometimes patients want all their teeth removed on the grounds that false teeth will look whiter.) What should the dentist do?
Here we reach the more general issues and move from aesthetics to ethics. Successive governments have expounded the doctrine of patient choice. But should the health professional do just what the patient wants? I’ll pose the question in another context. Suppose I want a new computer for the small needs of a retired professor – mainly emails and word processing. I go to a shop and the assistant advises a certain model at a reasonable price. But my eye lights on another model with a splendid screen-saver. I say I want that one. The assistant patiently, or pityingly, explains that that one is much more elaborate – for scientific purposes – and much more expensive. But I insist.
Has the assistant a duty to refuse the sale? No, he has given honest information and advice fearlessly, and if I insist, and put my money down, he can with clear conscience sell the computer, to a total idiot – that is part of the ethics of the free market. But can free market consumerism transfer to the professions? Consider first publicly-funded professions. If equity is to be a value of our society professionals must act as gate-keepers and deliver treatments and services only according to need. Consumer choice cannot consistently exist in a publicly-funded service because patient choice for expensive and unnecessary treatments and services will always be at the expense of other patients, and it is the professional’s job to decide what is necessary.
What if (as in the US) health care is not publicly funded? Well, if health-care professionals provide treatments or services not in the patient’s best interests simply because the patient has chosen them then they have ceased to be professionals, and become salesmen. One problem with the NHS is that nowadays it is in a confused position between a service that is publicly-funded and gate-kept and one that is consumerist and patient choice led. Dentists in the UK are in an especially difficult position because they run small businesses; more than doctors they face the tension between professional integrity and commercial viability.
I suggest that if you really want to be like Blair, Brown, Major or White Fang and dazzle your friends with your whiter-than-white teeth, or if you want to convince yourself that you are still 22, you should simply buy over-the-counter whitening toothpaste.
Robin Downie is emeritus professor of moral philosophy at
Glasgow University