Introduction

'It takes many good deeds to build a good reputation and only one bad one to lose it' – Benjamin Franklin.

Affleck and Macnish must be congratulated for provoking discussion around the extent to which the dental profession suffers reputational damage through the actions of individual professionals, especially through the use of social media. This article is written as a response to address several points that the authors raise in their 2016 BDJ paper, 'Should 'fitness to practise' include safeguarding the reputation of the profession?'1 These are firstly, whether social media can truly be considered to be classified as being an aspect of private rather than public and professional life. Secondly, I will question whether a position stating that behaviour and actions in a dental professional's private life do not necessarily have a bearing on their performance is tenable and examine how professional and personal behaviour are intricately interwoven. The authors parallel Nadia Armstrong's situation to other hypothetical scenarios stating that there is an unfair duality in management. I will re-examine these and argue that the principle for managing these based on notions of professionalism are the same. Finally, I will consider the idea of moral luck and how our attitudes to this notion are also determined by our concept of professionalism.

Personal or private?

Let us consider two situations; the first is that of Nadia Armstrong, the dental nurse who was reprimanded by the General Dental Council's (GDC) Professional Conduct Committee (PCC) on 8 March 2016. Her transgression was posting on the social media website Facebook, a message celebrating sectarian violence against Catholics in Belfast. The second is that of a hypothetical, registered dental professional who takes part in a non-peaceful protest against lawful immigration of a certain demographic hosted by a group that has fascist sympathies. Both are questionable activities with regards to their lawfulness; especially when both could be considered to be inciting hatred. Do we look at these situations to be completely separate or are they in principle the same?

One of the questions that arises from the case of Nadia Armstrong is how social media relates to the general principles of professionalism? Affleck and Macnish use the examples of Nadia Armstrong and Walter Palmer (the dentist infamous for killing Cecil, the Zimbabwean Lion) to illustrate the dangers of social media to our professionalism and how we might be perceived by the public. Studies from both the disciplines of dentistry and medicine illustrate the division of perception that exists between professionalism in the digital and real worlds. Resentment of requirements of professionalism by health professionals in the digital world is common2 while a study of the Facebook pages of dental students found that a relatively high number of students had questionable content on their profiles and unprofessional photographs. Of those with unprofessional content, over half had publicised their status as dental students at a particular institution.3 Professional and private behaviour may be seen to be distinct, however, if one's status as a registered dental professional is attributable to an act or conduct, any distinction ceases to exist. Affleck and Macnish acknowledge that privacy on social media is not a defence; material in private groups is easily removed and made public. Social media must be seen as an extension of one's professional persona and not purely as an extension of one's private life. Acts that would normally be seen to be altruistic such as dental volunteering can be undermined by the posting of pictures on social media that degrade those who are supposed to be the beneficiaries of such activities.4 There needs to be an acceptance within our profession that we still do not have a full appreciation of how social media impacts our clinical practise and relationships with patients.5 Affleck and Macnish conclude in their article that personal and private behaviour does not have relevance to the protection of the public and to the maintenance of the profession's reputation. Even if we support this conclusion, this might still not remove behaviour on social media from the auspices of the professional regulator if we consider online platforms not to be truly private. When we consider that patients are likely to search for their treating health professionals online,6 we cannot ignore a need for dental professionals to subscribe to concepts of eprofessionalism.7 Just as Nadia Armstrong would presumably not wear her extreme sectarian beliefs on a tshirt to work, she should not have posted them on Facebook either. The ideas of a professional and non-professional life are not necessarily dichotomous and may exist rather on a continuum whereby the two merge. This would suggest that dental professionals should practise great consideration to what information they place on Facebook and other social media platforms and how a reasonable member of the public might perceive them should they see this.

A higher standard

Affleck and Macnish acknowledge that members of the dental profession are held to a higher standard of behaviour and part of this involves prescribing to set ethical codes. The authors do not develop upon this further and later seek to limit the power of the General Dental Council in the context of maintaining the profession's reputation. It is important to state therefore, that the General Dental Council is not the progenitor of this requirement for the dental profession's adherence to a set of ethical principles that do not apply in the same way to the general public. Dental professionals are privileged and protected in position and title. The cost demanded for this by society is that professionals are expected to behave in a manner that is congruent with placing patient interests first but also with the inherent moral nature of providing care.8,9This is the reason for the existence of documented guidance such as Standards for the dental team,10 the standards set out in this code could be mistaken as being the will of the regulator; in fact they are the will of society. The idea that we might change these to make them more compatible to our needs is contrary to the spirit in which they were written.

The authors assert that as we are all flawed creatures, vulnerable to poor behaviour, our characters should be disregarded and it should be the competency of our immediate clinical care that is solely assessed. This should be challenged on several grounds; firstly on the basis of assumption that a clinician's character and clinical competency are not intrinsically linked. One might be able to fill a cavity in a technically sound way, but if a deficiency in character might lead to overcharging the patient for that treatment, any such individual would not likely be described to be a competent clinician in a truly holistic sense. Secondly, while the authors' example of being friendly with people at work who we might avoid actively outside of that context is reasonable, it does not apply to the sanctity of the caring relationship. Cruess and Cruess state, 'Caring, compassion, altruism and commitment are essential parts of the professional identity of every practicing physician and also represent fundamental expectations of patients and the public. Expressing them must spring from a sense of who a physician is, rather than just what they do.'8 It would be inappropriate to consider that those who harbour prejudice, ill-feeling or malice towards a particular group of society can be effective clinicians so long as they remember to put on their 'work-faces' before seeing patients. In a climate where comment of a hateful nature against racial, religious and other minority groups is increasing under the false pretence of free-speech, as a profession we must be mindful not to allow such behaviour to begin to become normalised in our sphere of practice. The GDC conceded that Armstrong appeared to be capable, caring and well-regarded,11 but the legitimacy in principle of the Council's finding and sanction derives from the fact that these attributes were truly negated by the hateful rhetoric she posted online.

The expectations that society holds of healthcare practitioners, has been diminished by tragedies such as the actions of Harold Shipman and the Mid-Staffordshire scandal. Despite this decline, the public's expectations remain high. Affleck and Macnish allude to an appreciation that the character of dental professionals is an important consideration. They use a hypothetical example of an unfaithful dental nurse who engages in an extramarital affair. The assumption that seems to be made is that society would judge this moral transgression to be equal to the posting of hateful material online. Each reader is free to make his or her own mind up on the issue of whether a philandering dental nurse would have a case to answer in front of the GDC. Personally, I wouldn't have any reason to question her trustworthiness and fitness to practise as infidelity in a relationship in itself is very unlikely to affect patient care. I would likely have more concern if she had a past conviction of fraud and was seeking involvement in financial matters. In the case of Armstrong, the finding that she was caring and capable has no bearing on the fact that the spreading of hateful rhetoric online does clearly threaten the reputation of the dental profession in being able to champion equal oral healthcare to every member of society. To state that it is unrelated to her practice as a dental nurse is clear sophistry.

Issues surrounding professional obligation and the effects of this upon conduct are illustrated well by the case of Robert Lattarulo. The Head of Recruitment at the GDC, Lattarulo called the Police when he was asked to leave a café for writing a bad review online in sight of the owner as a consequence of being given a different teabag to the one he had ordered. He was offered a refund and a replacement but reacted in a way that was seen to be risible. Lattarulo became a figure of fun within the dental profession and wider society when stories appeared in The Telegraph,12 The Daily Mail,13 The London Evening Standard14 and The Mirror15 about the incident. Had Lattarulo acted unlawfully? Certainly not, but he did nothing to dispel the current feeling within the dental profession that the GDC is disproportionate in its responses to complaints. Some called for the GDC to hold Lattarulo to account for his behaviour that had undoubtedly made his employer look foolish; several of the media articles mentioning his occupation. The implication behind this is that the non-professional employees of the GDC should be held to some degree of account with parity to those they regulate. Thankfully for Lattarulo, being a member of the public and not a dental professional, he is under no obligation to behave in any way other than that which is lawful. As dental professionals, we are held to a higher standard and could therefore expect to come under investigation if our behaviour, public or private falls below that expected as outlined in professional guidance. As dental professionals, we should not resent this higher standard; to do so is to disregard the nature of our professionalism and the terms of the social contract we hold with society.

It would be easy to criticise the GDC for acting disproportionally in their attitudes to reputational damage of the profession; of late some of the actions of the regulator have been questionable and potentially contributory to damaging the profession's reputation.16 However, on this issue of professional disrepute, the GDC is in agreement with the Solicitors Regulation Authority (SRA). Past Chief-Executive of the SRA Antony Townsend (who before this role acted as Chief-Executive of the GDC) stated in relation to the conduct of solicitors:

'Disciplinary action is generally taken where a solicitor commits a serious offence such as drink driving, however, it is not always breaking the law that may cause difficulty - a solicitor writing a blog in which they make lewd or racist comments would be at risk under this principle. A drunken solicitor at a private party would not be in difficulty, but one who got involved in a brawl as a consequence would be.'17

Moral luck

Affleck and Macnish state that often issues of reputational damage rely on moral luck. As an example, consider two men at a bar. They drink equal amounts, both becoming inebriated and equally over the drink-drive limit. They both decide to drive home, the difference being that in doing so, one of the men hits and kills a pedestrian while the other arrives home without incident or police scrutiny. Which man has acted with more moral fibre? While there are only legal implications for the driver who hits and kills the innocent bystander while drunk, both men are equally morally guilty. The authors seem to be suggesting that as this issue relies so much upon both the fickleness of what the public might take interest in and upon moral fortune, that disciplinary matters centering on reputational damage relating to the personal lives of registrants are not appropriate. This leads them to the conclusion that the GDC has no role in deciding what is offensive enough to warrant a claim that behaviour has brought the profession into disrepute. This assumption only works if we accept a paradigm where dental professionals have one moral standard when treating patients and another, lower standard, equal to non-professionals, when outside of work. There is a question to be addressed as to whether it is acceptable to consider professionalism to be a temporally based concept. If it is, then presumably the GDC would also have no place in exercising the cancelling of a professional's registration based on a conviction relating to conduct outside of work, unrelated to their practise. The GDC exercises a protective jurisdiction; one of the aspects of this is that professionalism is a constant requirement of a professional's conduct while they remain registered. The protection of the profession's reputation extends towards the protection of the public and their safe and equitable access to oral healthcare.

It is my view that the GDC is not acting in a manner that is outside of their jurisdiction in managing the profession's reputation and that their standards guidance does not need to be reviewed on this basis. To return to the example given by Affleck and Macnish of the unfaithful dental professional who has an affair with a politician and this comes into the public eye. If this causes the dental profession to fall into disrepute, then GDC interest in that professional's conduct would be justified. While infidelity might in itself be thought to be morally repugnant, it is the fact that the behaviour brings unwelcome scrutiny upon the profession as a whole and its ability to provide appropriate patient care that causes this to be a matter for regulatory investigation, not the behaviour itself. Professionals are entitled to a private life, but if this is incompatible with our professional role and public exposure would compromise this, we must question whether such behaviour is acceptable even if we are not involved in patient care at that time.

Conclusion

Affleck and Macnish are right to question the issues that surround the issue of fitness to practise and reputational damage. I feel that on this occasion their conclusions are not supported by the requirements of professionalism to which the dental profession is held by society. However, I am aware that there are others who feel that society may no longer support the notion of regulatory action in cases where bringing the profession into disrepute is the sole charge against a health professional.18

Further conversation in this area would be welcome and I invite correspondence either in the form of letters to the Editor or as direct contact in order to compose a follow-up article. Professionalism isn't a concept that can be turned on and off; the idea of professional behaviour only being required at work is not congruent with society's expectations of us. The authors may not support this interpretation, but their article presents professionalism as a skin-deep concept. I hold that it must be far more than this. If, like Nadia Armstrong, our behaviour is found to threaten the confidence of the public in our profession, we should be held to account. We cannot suggest that moral luck dictates the fairness of taking action. We also have to account for the changes living in a digital world means for our interpretations of privacy; nothing we do or post on social media is truly private and we must be careful to foster ideas of eprofessionalism. Nadia Armstrong undoubtedly risked bringing the profession into disrepute with her online behaviour. The GDC must continue to meet such reputational threats in order to protect the integrity of the profession and the public's trust in our ability to place them first.