The Influence of Ethical Standards upon Clients’ Behavior at an Orthodontic Clinic
ABSTRACT
The growth in market competition in the last years has yield changes in the dental market, especially in the way dental professionals communicate with clients. A communication grounded on ethical concern is likely to improve relationships with clients and increase their perception of what is really provided. Strong competition and ethical restraints experienced by a professional are reasons for looking for a better understanding of this topic by assessing dentists’ ethical behavior as a factor influencing clients’ decision making. Ethics and marketing are the theoretical underpinnings of this paper to shed light on the topic.
The methodology consists of a qualitative and exploratory research collecting data by means of depth, non-structured interview. The results point out that dentists’ ethical behavior does influence clients’ decision making. On the one hand, dentists claim they attempt to work within ethical, health standards. On the other hand, clients identify the following factors as determinants for their choice: ethical issues, information on treatment, caring and human support, safety of the facility, prioritization of treatment over finance.
Elaine de Oliveira Pereira
José Marcos de Carvalho Mesquita
The Influence of Ethical Standards upon Clients’ Behavior at an Orthodontic Clinic
1 INTRODUCTION
The growth of the service industry has come along with increasingly demanding and discriminating consumers. As for an organization’s ethics policy, some have claimed that information availability and awareness of consumer rights would count for consumers more inclined to punish companies for their unethical actions and to favor those performing ethically (Webster 1997; Carrigan and Attalla 2001 In A ÉTICA… 2003). Nevertheless, despite the common presence of information systems nowadays, several people cannot distinguish deceitful health publicity from ethical health publicity. This topic was approached in the I Forum for Medical Publicity Regulation, promoted by the Medical Board of the State of Sao Paulo (Brazil) in November 2005.
Even though no civil relation is granted in the Brazilian Code for Consumer Defense when a patient goes to a clinic looking for dental or medical care services, this Code does regulate any event of medical publicity claiming positive results. Furthermore, as Nunes Junior et al. (2005) say, the administration of a treatment building on ethical foundations and honesty is likely to yield both consumers’ fidelity to and success for a company.
Against this background, this paper reports on a study aiming to assess the influence of ethical standards upon clients’ behavior at an orthodontic clinic in Belo Horizonte, State of Minas Gerais, Brazil. More specifically, it aims at identifying and assessing the features that influence a client’s choice of an orthodontic care service and also assessing consumers’ satisfaction with the orthodontists’ ethical behavior.
As a result of new demands related to efficiency, innovation and competition, this paper approaches ethics in marketing for a better understanding of the demanding, current economic system and the increasing complexity of contemporary practices.
2 REVIEW OF THE LITERATURE
Ethical doctrines emerge and evolve in different times and societies as responses to problems faced in human relationships and in their actual moral behavior. Ethics relates to reflection and approaches historical morals to identify what is right or wrong in a given community. It studies human behavior considered worthy and mandatory. To assume an ethical stance means to reflect upon choices to be taken, to care about other people, to cater for others’ good and to be esponsible for one’s own attitude (Srour 2003).
Since ethics theorizes upon moral practices, it is important to stress the two major theoretical frameworks on ethical decision making (Srour 2003). Teleological ethics, or ethics based on consequences/responsibilities, approaches consequences in decision making, the best choice being that most likely to benefit as many people as possible. On the other hand, deontological ethics, or ethics based on conviction or duties, leaves no room for any exception—an act is right or wrong because of its very nature rather than its consequences (Fortes 1998).
Besides the assessment of financial performance in any organization, ethical matters— eg., sales-related issues like bribery; propaganda-related issues like deceitful propaganda; and roduct-related issues like quality and safety (Kotler 2000)—must also be taken into account n several aspects of any business. Particularly for service providers, according to Bateson and offman (2001, p. 458), “‘ethical issues’ include critical changes accounting for illegal, moral, hazardous, insalubrious and other behaviors that stray from social standards.” The uthors established four categories of unethical behavior, namely: 1) dishonest behavior tands for service providers who charge for labor that did not exist or who suggest nnecessary services; 2) intimidating behavior stands for the use of aggressive sales echniques; 3) hazardous or insalubrious practices stand for serving inappropriate food and handling money; and 4) conflict of interest stands for situations where professionals orient their actions towards better commissions rather than clients’ satisfaction.
According to Srour (2003), any decisions and actions that do not fit into the standards of any of those two theoretical framework (conviction or responsibility) shall be considered unethical, any selfish or exclusivist attitude being pronounced unethical. In health, this translates in every patient being treated to cater to their health needs rather than to satisfy one’s interest, especially health workers’.
3 METHODOLOGY
This research takes a qualitative approach, as indicated for those studies aiming at interpreting consumer phenomena, relations between attitude and behavior, or also the process of purchase-related decision making itself (Vieira and Zouain 2006). It consists of an exploratory research, since this type of research aims at developing and explicating concepts of a given group of clients and also analyzing how they perceive a professional’s ethical behavior (Triviños 1987). It is also a study case of a specific orthodontic clinic, this technique involving the deep study of a given reality likely to pose hypothesis for future research (Triviños 1987).
The sample consists of a group of three dentists and 30 out of 300 patients that had made monthly appointments regularly in the last two years. Although four dentists worked in the orthodontic clinic, only three of them held specialization in orthodontics, which accounts for the fact that the unit of observation comprises only three dentists. Since the orthodontic clinic restricted the days for data collection, these 30 patients constitute a convenience sample of ten parents of children 4 to 14 years old (most appropriate ages for bone treatment), ten patients 15 to 25 years old (most suitable ages for corrective orthodontic treatment), and ten patients 26 to 50 years old (patients usually aware of their need for orthodontic care who usually afford treatment costs, and usually patients with the top age for this sort of treatment).
The research resorted to the in-depth interview technique, which deeply studies a few objects in a straightforward, non-structured way to collect information and to shed light to a research problem (Malhotra 2006). The process comprised an initial issue-related question— “What resources does the orthodontic clinic use to contact clients and provide them with services and related information?”—followed by a non-structured, focused interview (Marconi and Lakatos 1996).
After data collection, the analysis technique chosen was content analysis, which, according to Bardin (2002) and Triviños (1987), is a set of techniques to analyze utterances and to find traces related to the conditions of message production/reception by means of specific procedures to describe their content. It comprised three stages, as posited by the authors: pre-analysis, involving transcriptions; analytical description, involving analysis, codification, classification, and categorization; and inferential interpretation, establishing relationships between interviewees’ responses and the research topics.
The research was carried out in an orthodontic clinic so-called Beta (codename) in Belo Horizonte, State of Minas Gerais, Brazil. For confidential reasons, the real name of the clinic is omitted in this paper.
4 RESULTS AND DISCUSSION
Aiming at a better understanding of the topic, this section comprises four subtopics.
4.1 Resources used to contact clients and provide them with services and information
According to interviews with patients at Beta Clinic, most interviewees pointed phone and face-to-face contact and a few of them reported written contact as response to the initial question “What resources does the orthodontic clinic use to contact clients and provide them with services and related information?”. Face-to-face contact was the most relevant, but those responsible for patients aging 4 to 14 claimed that information is insufficient.
According to interviews, contacts are established directly with patients or parents whenever necessary. However, parents feel they need more regular information, which should be provided as an initiative of the orthodontists themselves rather than the parents’. According to a father, “[…] information comes if you look for it. In every appointment, since they are short, I think, they should call the parent and explain, let us know the topic” (parent 5).
4.2 Features influencing clients’ choice of a health (orthodontic care) service
Features influencing a patient’ choice of a given orthodontic care service are word-ofmouth, aesthetics and functional issues. The data show that those people indicating a service, such as a relative that undertook a treatment or health professionals, are those aware of either an aesthetic or functional need for orthodontic care.
4.3 Features influencing clients’ choice of a given health professional (orthodontist)
According to interviewees, word-of-mouth is the first step to get to a given professional. However, this professional’s competence and behavior, especially in terms of providing information, are determinant for the final choice. Word-of-mouth takes place as a result of satisfaction with the service provided, as shown in the excerpts below:
a) “This Dr. […], he is the one we usually recommend to other people, since we have had satisfactory feedback regarding him” (parent 4);
b) “Recommendation from a speech therapist. Because mothers whose kids had appointments with Dr. […] gave us this information. She told me about this doctor, I talked to some mothers whose kids were under treatment and I liked of what I heard of” (parent 8).
4.4 Health professional’s ethical behavior influencing clients’ choice
According to the following statements, ethical behavior plays an important role in clients’ choice of an orthodontist, as most interviewees deemed it as an important factor determining their choice:
a) professional’s seriousness, not aiming exclusively at profit (parent 1);
b) professional’s attitude of competence, self-confidence and responsibility (parent 2);
c) professional’s supply of the exact information needed by the parent:
“[…] it would be very comfortable to her if she […] made a fool of us, but it is not like this. She actually explains why to do anything, how long it is necessary to wear braces, how they will check if there is any need of change. She explains how long it takes for feedback, and we do have feedback. As for professional ethic of every professional in here, I myself see this as the main reason for me to keep bringing my kid to this Clinic.” (parent 4)
d) professionals shall provide all the relevant information, which, however, does not exclude the possibility of parents feeling anxious for more information: “I felt she was trustful, but sometimes I feel that something is missing. I have always been a mother who likes more information; I want to understand more; I feel afflicted.” (parent 6)
e) how the professional deals with patients and parents:
a) “[…] they talk; they explain what is going on with the teeth; how the treatment is succeeding, how it will work; they make it very clear.” (patient 6)
b) “There must be care and support. It’s not only about treatment itself, but also the patient’s psychological condition, which is quite important.” (parent 5)
f) Clinic’s infrastructure, organization and processes:
“The first thing we notice is the infrastructure of the Clinic. For instance, we get here, and everything is very tidy and neat; we are treated in a place different from where they handle money.” (patient 4)
g) Professional’s behavior with clients:
“[…] the professional’s behavior with clients; that’s what calls my attention.” (patient 8)
h) financial issue:
“[…] we have gone through hard times. I would interrupt treatment, […] but he didn’t allow me, and said we had to keep the treatment, he had to finish his job.” (patient 1)
Even though financial conditions were not a significant factor for a client to start his/her treatment, they were relevant in maintaining the treatment. For this relevance for the patient, financial conditions were mentioned as an ethical issue in the choice of a given professional. Being important for some patients and pointed out as one of the features determining their choice, they stated:
a) It was word-of-mouth indeed. […] because of trust in the dentist’s referral. (patient 2)
b) Transparency in explanation: what could possibly happen or not. This ethic brought me here and stimulated me to start treatment. Seriousness, being frank with the client. (patient 13)
The main topics approached in this section are summed up in the next chapter, Final Remarks, as follows.
5 FINAL REMARKS
Results point out that both clients and professionals find it hard to deal with ethical issues. However, they mention ethic examples even ignoring the actual theoretical meaning.
According to Srour (2003), when laypeople talk about ethic or moral, they refer to agents’ strength of mind. For them, to be ethical means to hold to their convictions, to have principles, not to despise one’s own ideals and beliefs, and to be a model of virtue and correctness.
Grounded on the methodology and theoretical underpinnings, the results open a space to reflect upon ethical factors influencing consumers’ choice of an orthodontist. The major factors, from the most to the least reportedly important, were: information on treatment, human and caring support, safety in the health facility (hazardous or insalubrious practices), and prioritization of treatment over financial conditions.
The first factor was information on treatment. The duty-oriented framework of ethics considers that everyone has the right to information and truth, irrespective of the consequences of the information provided (Fortes 1998). According to interviewees, they feel safer when they are aware of the risks involved. Being well informed on the whole process since the very beginning, they feel calmer over their search for the best results and they are granted the right to consciously undertake or refuse the treatment proposed. The patients reported they were satisfied with the information provided, whereas parents generally reported insecurity because of a lack of communication with the orthodontists even though they were given the most relevant information. According to most parents, they themselves were supposed to look for the orthodontists in order to get some sorts of information about their children’s treatment; however, they believed that orthodontists should take the initiative to provide them with pieces of information that apparently were not absolutely relevant.
The second factor was human and caring support, standing for the way a professional deals with parents or patients. According to Fortes (1998), patients have the right to human and respectful care by health workers, who shall be thoughtful in the face of patients’ and parents’ statements, state of mind and limitations.
The third factor was safety in the health facility. Every patient has the right to safety in the health facility (Fortes 1998), and service providers shall never resort to hazardous or insalubrious practices (Bateson and Hoffman 2001). Some interviewees mentioned the oganization of the Clinic in terms of department layout, especially for the appointment 6 division being isolated from the finance division. The forth and last factor was the priority of treatment over financial conditions.
Bateson and Hoffman (2001) say that service providers’ charging for unnecessary or unperformed labor falls into the category of unethical behavior. Some interviewees mentioned their freedom to interrupt treatment when a patient does not wear braces properly or when an orthodontist has not started treatment yet waiting for the ideal moment. Other factor influencing patients’ choice of a professional is the result of a treatment.
Although it is not directly linked to ethical issues, it does indirectly pervade the whole process. Most patients reportedly come to Beta Clinics due to word-of-mouth, particularly because someone mentions the professional because of their satisfaction with the treatment process and the result itself. Therefore, satisfaction does not only relate to treatment itself, but also to a professional’s commitment and responsibility with the patient.
Professionals’ competence, kindness and manifested reliability, responsibility and safety are features that influence clients’ perception of service quality (Zeithaml and Bitner 2003). The authors say that consumers have a need to be fulfilled and thus look for information to support their satisfaction over this need. In order to find the desired information, a client resort to personal sources, such as friends or specialists, and also to nonpersonal sources, such as mass or segmented communication. Since any means of communication can inform on features of a good service, but hardly inform on experience, clients have usually relied on personal sources. Moreover, assuming that they cannot access several features before buying a service, they are likely to opt for an alternative they already know.
In sum, the factors listed by the interviewees match the dimensions posited by Gronroos (2004), namely: information, reception, and prioritization of health (those related to functional features) as well as safety of a facility (this related to technical features).
Interviewees did not mention that their consent on treatment was the result of psychical or moral constraint by means of manipulation of facts or data. According to Fortes (1998), consent shall not be the result of any means of manipulation preventing one’s manifestation of one’s own will. Data show there was transparency in the information provided by the orthodontist whenever they were requested. According to Sanchez Vázquez (2007), consumers have needs that are not theirs necessarily, which means they lose the ability to decide on their own under the influence of publicity and persuasion techniques.
They are manipulated to consume and eventually buy something virtually imposed, irrespective of their actual needs. No interviewee mentioned pictures showing patients’ teeth “before” and “after”, probably because that would mean orthodontists’ manipulation and, for instance, generalization of successes and concealment of bad outcomes.
Finally, any companies concerned with their corporate image, brand value or prestige introduce ethical reflections in their strategy, since reputation is one of the most vulnerable attribute of a company (Srour 2003). Lack of reputation equates with lack of collective trust, a traumatic situation similar to cheating in a long relationship. Therefore, companies understanding ethics as a powerful tool to implement competitive and competent strategies are quite likely to profit.
Since this research involves some limitations, future research shall address the following:
a) Study of other health specialties and regions of Brazil for comparison of results;
b) Quantitative study for deeper analysis of the topic drawing on more representative samples.
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