Social Science & Medicine 55 (2002) 323–329

Dentistry and distributive justice

Shafik Dharamsi, Michael I. MacEntee*
Department of Clinical Dental Sciences, Faculty of Dentistry, University of British Columbia, 2199 Wesbrook Mall, Vancouver, BC,
Canada V6T 1Z3

Abstract

There is a growing concern in most countries to address the problem of inequities in health-care within the context of
financial restraints on the public purse and the realities of health professions that are influenced strongly by the
economic priorities of free-market economies. Dental professionals, like other health professionals, are well aware that
the public expects oral health-related services that are effective, accessible, available and affordable. Yet, there is
remarkably little reference in the literature to the theories of distributive justice that might offer guidance on how an
equitable oral health service could be achieved. This paper considers three prominent theories of distributive
justiceFlibertarianism, egalitarianism and contractarianismFwithin the controversial context of basic care and
quality of life. The discussion leads towards a socially responsible, egalitarian perspective on prevention augmented by a
social contract for curative care with the aim of providing maximum benefit to the least advantaged in society. r 2002
Elsevier Science Ltd. All rights reserved.

Keywords: Dentistry; Basic care; Quality of life; Distributive justice; Health services; Social contracts

Introduction countries (General Accounting Office, 1991; Cust,

There is the view that dentistry is a health service
accessible only to the more advantaged members of
society (Field, 1995; Chen, Anderson, Barmes, Leclercq,
& Lyttle, 1997; Jones, 1998), yet, evidence is mounting
that loss of teeth and other dental problems are more
prevalent, and the consequences more serious, among
lower income groups (Miller, Brunelle, Carlos, Brown,
& Lo. e, 1987; Todd & Lader, 1991; Charette, 1993;
DHHLGCS, 1993). Discussions in several countries and
councils in Canada, USA, UK and Sweden about
equity, accessibility and justice in health-care generally
are changing the delivery of health services, including
dental services. (Epp, 1986; Atchison & Schoen, 1990;
Rosenthal, 1992; ADA Council on Ethics, 1995;
Bradshaw and Bradshaw, 1995; Hill, 1996). There is
favour for some level of universal health-care and it is
high on the policy agenda in many industrialized
*Corresponding author. Tel.: +1-604-822-3564; fax: +1-
604-822-3562.
E-mail address: macentee@unixg.ubc.ca (M.I. MacEntee).
1997). A Presidential Commission in the USA (1983),
for example, proclaimed society’s ‘‘moral obligation’’ to
ensure adequate health-care for all, and the American
College of Physicians (1990) called for a national policy
to ‘‘minimize financial barriers and assure access’’ to
health-care. There is general agreement today that basic
health-care should be distributed equitably, however,
there is little consensus on what is meant by basic care,
especially within the context of oral health (WHO,
1978). Inequities in oral health abound because of social
and economic factors. Children from low-income
families in the USA have substantially more decayed
teeth and more untreated oral disease generally than
other more affluent children (US Department of Health
and Human Services, 2000), and social status is the most
important factor explaining differences in caries among
European children (Bolin, 1997; Sweeney & Gelbier,
1999). Moreover, the promotion of foods high in sugar
content is targeted frequently at poorer groups who, as a
result, are placed at an increased risk to caries and
tooth-loss (Gamble & Cotugna, 1999). This tooth loss
can limit employment opportunities and compromise

0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.
PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 1 7 4 - 5
324 S. Dharamsi, M.I. MacEntee / Social Science & Medicine 55 (2002) 323–329
the nutrition and health of individuals. The problem is
compounded even further in dentistry by tensions
between the moral values that identify it as a health
profession and the commercial values of practice where
the impetus is on entrepreneurial self-interest. In an
effort to clarify the options available to the dental
professions and to societies feeling this tension, we have
introduced here the prominent concepts of distributive
justice that can lead to an equitable distribution of oral
health-care.
The right to health-care
In 1948, the Universal Declaration of Human Rights
from the United Nations asserts ‘‘everyone has the right
to a standard of living adequate fory health and well-
beingy includingy medical care and necessary social
services’’. Although the current debate on health-care as
a moral right is rooted in social and religious concepts of
charity, beneficence and compassion (Chapman &
Talmadge, 1971), recently there has been an effort to
promote a more inclusive view of health-care and equity
in health that recognizes the significance of distributive
justice (Barry, 1989; Whitehead, 1992). The World
Health Organization (1998), for example, has refined
its view to include the various rights and responsibilities
of individuals and of society to promote health. The
theoretical support for this more inclusive view is
derived more from the egalitarian and contractarian
theories of justice than from libertarianism. Essentially,
the responsibility of health promotion poses the obliga-
tion on individuals and on society to develop healthy
practices and to refrain from actions that threaten
health, with the clear possibility of forfeiting rights when
there is intentional participation in risky or careless
behaviour (Lindbladh, Lyttkens, Hanson, & Ostergren,
1998). Libertarians, on the other hand, support the right
of personal autonomy over the demand of health
promotion, despite the risks. Yet, struggles with the
inequities of health-care continue to revolve around the
distinction between basic care and elective or discre-
tionary care.
About a quarter of the population in North America,
usually the least advantaged in society, visit dentists for
little more than emergency care (Miller et al., 1987;
Charette, 1993). In South Africa, over 75% of the black
population reported visiting the dentist or dental clinic
for symptomatic reasons (Van Wyk, Faber, Van Rooy,
& Olivier, 1994). Although it is not clear how much of
this behaviour is due simply to poverty, at least it does
raise concern about the way dentistry is offered (Weiss,
MacEntee, Morrison, & Waxler-Morrison, 1993). Den-
tal services through Medicaid in the USA are unique
among all the health services to have sustained a decline
(30%) in public expenditures since 1975 (Oral Health
Coordinating Committee, 1993). Similar concerns about
access to other health services prompted Daniels (1985)
to suggest that everyone should have an ‘‘equality of
opportunity’’ as proposed by Rawls (1971) to maintain a
reasonable quality of life through an equal opportunity
for basic care. Daniels’ suggestion addresses five
essential services: (i) food and shelter; (ii) safe and clean
habitat; (iii) exercise, rest and recreation; (iv) health-
care; and (v) social supports. He did not define ‘‘quality
of life’’ or ‘‘basic care’’, nor did he indicate how much
opportunity a society can afford or who should have
access to the opportunities. Nonetheless, it is a four-
tiered management process that addresses prevention,
rehabilitation, management of chronic disorder, and
palliative care. However, it has also the potential of
being a very expensive approach to health-care, almost
to the point where financial costs could overwhelm
benefits. Concern for costs in many countries, most
notably in the Netherlands (Government Committee on
Choices in Health-Care, 1992), Britain (Roberts, 1992)
and Canada (Mhatre & Deber, 1992), and even more so
in developing countries, poses a significant challenge to
universal care and endorses the idea of rationing care in
favour of those with greatest need.
Quality of life
Quality of life is a complex and multidimensional
concept that has been associated in recent years with the
outcome of health-care. It refers usually to a mix of
biological, psychological and social dimensions of illness
from the perspective of the patient (O’Boyle, 1997). Its
influence on physical functions, emotions, cognitive
awareness, life satisfaction and economic status has
caught the attention of researchers interested particu-
larly in chronic disease, yet it remains a vague concept.
More recently, the term ‘‘health-related quality of life’’
has emerged to focus on ‘‘the value assigned to the
duration of life as modified by the social opportunities,
perceptions, functional states and impairments that are
influenced by disease, injuries, treatments or policy’’
(Patrick & Erickson, 1993). Unfortunately, there is no
agreement either on how this relates specifically to basic
care, and, like the expansive 1947 WHO definition of
health, it probably has little practical value for public
policy (Evans & Stoddart, 1994). Nonetheless, the
concept of health-related quality of life could have
practical meaning within the specific confines of oral
health-care (Slade, 1997). Oral health is an essential part
of the daily comfort, hygiene and general health of older
adults (MacEntee, Hole, & Stolar, 1997), and oral
health-care a constant concern for caregivers in long-
term facilities (MacEntee, Thorne, & Kazanjian, 1999).
Despite the apparent banality of tooth-loss, a defective
dentition can disturb eating, speaking, general appear-
 S. Dharamsi, M.I. MacEntee / Social Science & Medicine 55 (2002) 323–329
ance and comfort, and it does precipitate serious illness
(Reisine, 1988). In fact, there are few adults who have
not experienced some problems relating to oral pain,
eating or appearance. Sick-leave is attributed more to
dental problems than to most other disorders (Hollister
& Weintraub, 1993), and the Provincial Health Officer in
British Columbia has disclosed recently that dental
treatments are the most common hospital-based surgical
procedures, usually involving general anesthesia, for
children under 14 years of age in the province
(Provincial Health Officer’s Annual Report, 1997).
Caries in children disturbs their growth and ability to
thrive (Acs, Lodolini, & Kaminsky, 1992; Ayhan,
Suskan, & Yildririm, 1996), whilst older adults are very
concerned about the social and personal implications of
their oral hygiene (MacEntee et al., 1997). In addition,
there is also some evidence linking poor oral hygiene
and periodontal disease with coronary heart disease,
although a causal relationship has not been established
(Mattila, Valtonen, & Huttunen, 1995; Beck, Garcia,
Heiss, Vokonas, & Offenbacher, 1996; Joshipura et al.,
1996; Howell, Ridker, Ajani, Hennekens, & Christen,
2001). In summary, it is increasingly more difficult to
justify the separation of oral health-care from other
health services.
Basic oral health-care
The varied circumstances of different communities
preclude a universal definition of basic health or basic
care. Therefore, each community defines its own health-
related expectations and requires appropriate resources
to meet those needs so that, according to the World
Health Organization (WHO), ‘‘everyone should have a
fair opportunity to attain their full potential’’ to ‘‘lead a
socially and economically productive life’’ (1995, p. 64).
The WHO falls short of providing guidance on how a
fair opportunity or equity can be attained. Attempts
have been made in several jurisdictions to ensure that
basic oral health-care is accessible to all. The State of
Oregon, for example, rations health-care to its residents
who are less well-of by measuring the cost-effectiveness
of various medical and dental services, with the idea that
cost-effective care refers solely to simple, preventive,
primary, inexpensive or acute care (Block & Freed,
1996). On the other hand, the very idea of basic care has
been challenged as morally untenable because it excludes
‘‘non-basic’’ care from the less affluent segments of
society (Veatch, 1991a, b). Indeed the concepts of cost-
effectiveness, cost-benefit and cost-utility of health-care
are all complicated and contentious measures (MacEn-
tee & Walton, 1998), and there are dentists who feel that
cost-effectiveness as a measure of basic care conflicts
with their ethical principles (Bryant, MacEntee, &
Browne, 1995). The Berlin Oral Health Declaration
325
(1995) contends that oral health can be maintained
simply and cheaply as part of an overall ‘‘prevention’’
strategy to restrict sugar consumption and enhance
personal hygiene. Curative strategies, in contrast, are
technically demanding and costly, especially when
replacing teeth and tooth-structure, and it is in the
realm of curative treatment where demands for basic
care so frequently conflict with treatment needs, in large
part because providers and recipients frequently have
very different perceptions of health. In any event, basic
oral health cannot be defined or addressed in isolation of
the general political and economic structures of society.
Healthy diets need food, and personal hygiene needs
clean water, while curative treatments need skilled
clinicians with costly equipment and supplies. However,
no matter how it is defined or identified, the need for
basic oral health-care is vast, even in North America,
and especially among those in the lower socio-economic
bracket (Mojon & MacEntee, 1994).
Distributive justice
Distributive justice addresses the distribution of
benefits and burdens in society (Cupit, 1998). It is based
fundamentally on the principles of social justice, which
offer moral directives to a just allocation of resources, a
fair compensation to providers, and a reasonable range
of services (Annas, 1995). There is a growing sensitivity
worldwide to the principles of social justice in an effort
to distribute health-care equitably (Whitehead, 1999).
The problem extends well beyond a discussion of simple
supply and demand, with factors such as social structure
influencing demand, and wealth or opportunity influen-
cing resources (Lamont, 1999). Nonetheless, we will
offer here a brief explanation of the more dominant
theories underlying the current concepts of social justice
to provide a context for distributing oral health-care
equitably.
Theories
Theories on social and distributive justice, of which
libertarianism, egalitarianism and contractarianism are
the most prominent, have emerged to support health-
care policies (Roemer, 1996; Van Doorslaer, Wagstaff,
& Calonge, 1992).
Libertarian theory is the hallmark of a free-market
economy where freedom of choice lies on the highest
moral ground (Nozick, 1974). Libertarianism in the
United States and Britain, for example, supports a
multi-tiered structure in which basic health-care is
financed publicly and elective care is bought privately.
The distinction between basic and elective care, how-
ever, is frequently very unclear. Libertarianism has been
used also to support the rights of individuals to neglect
326 S. Dharamsi, M.I. MacEntee / Social Science & Medicine 55 (2002) 323–329
their health without social interference unless the neglect
causes damage to others. This concern about damage to
others has centred largely in the debate about tobacco-
use and the right of society to limit the liberty of some
for the betterment of all (Beauchamp, 1991).
Egalitarianism, in contrast, holds that everyone
should have an equal claim on all available resources,
and that health is a necessary precondition to an
‘‘equality of opportunity’’ in life (Outka, 1974). It
supports the principle of sharing all health resources
equally as a social responsibility (Veatch, 1991a, b). The
Canadian health-care system, for instance, professes a
health service to all without inequalities or disadvan-
tages (Naylor, 1998), although there is a growing
concern that access to health-care in Canada is less
egalitarian today than originally intended. The feasi-
bility of an egalitarian health service hinges on the scope
of the service and the economic support available, which
harks back to the idea of ‘‘basic’’ health-care and the
‘‘bottomless pit’’ of demand. The European office of the
WHO favours the principles of equal access to available
health-care, equal utilization for equal need, and equal
quality of care for all (Whitehead, 1992). When pitched
against these principles, the curative focus of contem-
porary dentistry appears quite inequitable.
Contractarian theory evolved from the belief, focused
by Rawls (1971), that social inequalities and disadvan-
tages are unavoidable, and that a fair and unbiased
social contract could be struck for distributing basic
needs to the population. In contrast to egalitarianism,
Rawls and his followers advocate a system whereby
inequalities and disadvantages are managed by distri-
buting our limited resources and services to the
maximum benefit of the least advantaged in society.
Rawls produces a scenario in which individuals sit
around a table to negotiate and formulate the immu-
table principles that will govern their social practices. He
poses that everyone at the table is informed fully about
the issues involved in the negotiations, including the
knowledge required to balance personal interests with
the potential fate of everyone else involved. All in
attendance know the relevant facts that affect life,
including the knowledge to balance personal interests
with potential fate. What is not known, however, is
everyone’s actual fate that deals out natural assets and
abilities, intellectual capacity and strength, and other
features such as gender, race, etc.; therefore, decisions
around the table are biased by the rational self-interest
of each individual. Rawls describes this feature of the
scenario as the ‘‘veil of ignorance’’ that provides a
measure of impartiality to the deliberations. Given this
scenario, Rawls believes that everyone at the table will
act with self-interest to gain maximum advantage,
especially since there is the very real possibility that
each individual could be the least well off because of
fate. Although it is not easy to make complicated moral
decisions involving all members of society, he contends
that it is relatively easy to make personal decisions in an
effort to gain a reasonable share of the benefits and
burdens of society. This ‘‘maximin’’ imperative, as he
calls it, offers everyone the possibility of protecting and
maximizing interests that are important and minimizing
burdens as much as possible. Certainly, inequalities are
not eliminated in this system, but they are arranged by a
social contract that justly provides the least well off with
the greatest opportunity to access all goods and services,
including health-care.
A proposal for equitable oral health-care
The policies and practices of dental professionals like
other health professionals reflect health-care increas-
ingly as a monopolized commodity serviced extensively
for profit (PEW Health Professions Commission, 1995;
Woodstock, 1995). Libertarian theory, as the hallmark
of a free-market economy, has widespread appeal in
many professional organizations. It favours the more
affluent members of society, especially in countries with
unstable economies, and it does not lead necessarily to
an equitable distribution of care (Mautsch & Sheiham,
1995). Egalitarian theory supports the distribution of
health-care without limits so that everyone can have
ready access to all available resources with health
considered as an essential resource. This idea has much
utopian appeal but it is losing support in many countries
because of growing concerns about public debt. Health-
care expenditures in affluent countries already run close
to 10% of the gross national product (USA 14%;
Germany 11%; Canada 9%; Australia 9%; and UK
7%) with the emerging view that the demand for health-
care is a bottomless pit (WHO, 1999). Hence, today the
moral resolve to provide care for the poor, the aged and
the disabled is constrained by strong economic and
professional factors. Nonetheless, we believe that most
health-care professionals take pride in offering a public
service that promotes the public interest and the
common good.
The principle of distributive justice that addresses the
fair sharing of benefits and burdens in society is
described most aptly in Rawls’ contractarian theory. It
promotes the cooperation of free and equal persons to
establish health-care as an essential benefit and burden
of society. We are attracted to this theory because it has
had a substantial impact on the topic of distributive
justice generally and it has been adopted, we believe
successfully, to address the unique concerns of health-
care. Moreover, Rawls’ ‘‘veil of ignorance’’ brings
impartiality or fairness to decisions about the distribu-
tion of care. There is no universally accepted definition
of basic care, nor is there agreement on how health and
health-care interacts with quality of life. According to
 S. Dharamsi, M.I. MacEntee / Social Science & Medicine 55 (2002) 323–329
the Berlin Declaration, the scope and content of care
remains for each society to define for itself based on its
specific resources and expectations. Clearly, expecta-
tions of care vary greatly between wealthy industrialized
communities and less wealthy agrarian communities.
Indeed, this negotiation process is far more complicated
than Rawls suggests, particularly in communities or
countries where language, culture, education and
economic status differ greatly. However, valid concerns
have been raised about the benefits of modern dentistry
with its emphasis on complicated curative treatments. If
the expensive curative model of dentistry continues to
prevail, as it has over the last century, then there is a
very urgent need for a social contract to ensure that the
maximum benefit will go to the least advantaged in
society. Indeed, this contract seems to be the most
socially responsible and self-interested course of action
given the very real possibility that fate could place
anyone of us among the least well off in society.
Alternatively, if the preventive model of care assumes
its rightful place in containing oral diseases and sickness,
then it might be possible fiscally to adopt an egalitarian
approach to oral health-care so that everyone can
benefit without distinction.
Conclusions
Dentistry is evolving to address personal and social
problems that stem in large part from a widespread
ignorance of diet and nutrition, hygiene and dental
services. The potential demands globally for oral
health-care are enormous, yet it is offered predominantly
as a curative art with only a small emphasis on the
prevention of disease. Moreover, there is no obvious
agreement on what constitutes a reasonable range
of oral health-care services, a just allocation of
resources, nor a fair compensation to providers.
Delivery of care can be viewed from several theoretical
perspectives, but the greatest rewards for society
can be derived from an egalitarian perspective on
prevention supplemented by a social contract for
curative care that will render maximum benefit to the
least advantaged.
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some people healthy and others not? The determinants of
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