New profession by fiat: Italian dentistry and the European common market

NEW PROFESSION BY FIAT: ITALIAN DENTISTRY AND THE EUROPEAN COMMON MARKET LOUIS H. ORZACK Rutgers University.

New Jersey. U.S.A

Abstract-Dentistry posed major problems for the European Common Market’s efforts to harmonize national arrangements for entry to practice by migrating professionals. The separation of dentistry from medicine in the other 8 member-nations did not occur in Italy. The 1978 Dental Directives passed by the Common Market Council of Ministers included special provisions requiring Italy within 6 years to authorize a new dental role Independent from medicine and to create appropriate specific training. The analysts of these events covers three elements. First. the elTorts of medical-dentists in Italy to reach consensus or to block a possible internal move toward creation of a separate dental specialty are appraised. Second. the actions of the international liaison committee of national dental associalions to seek to deal with the Italian problem through contacts with the Italian medical profession. with the sub-group of Italian medical-dentists. and with the international liaison committee of national medical associations are reviewed. Third. the actions undertaken by Common Market bodies are analysed. This unusual instance of an international governmental authority seeking to force changes in the structure of a professlon by impelling action by the government of a sovereign nation highlights the need for further cross-national analysis of the relations between professions and political systems. Whether health professions are more susceptible to international harmonization than technical, scientific, financial or design professions remains an open question. until such research occurs.

under this Directive. Italy is obliged to create a new category of professional persons entitled to practise dentistry under a title other than that of doctar;. . . in creating a new profession Italy must not only introduce a specific system of training.. , but also set up structures proper to this new profession, such as a council,. . . Italy shall take these measures within a maximum period of six years [I].

When the European Economic Community or Common Market, operating with the sanction of the governments of its member nations and under authority provided by the 1957 Treaty of Rome, sought to harmonize national arrangements for entry to professional practice by migrating individuals. the field of dentistry. especially in Italy, presented a major problem. No profession of dentistry existed in Italy as the field there had not earlier split off from medicine. In a pattern unique to the Common Market countries, any medical doctor in Italy is legally able to practice dentistry. Entry to work in Italy has been blocked to dentally-qualified persons from elsewhere in the realm of the Common Market. Italian medical doctors, even those stressing dental care in their practice, have been unable to acquire rights to practice dentistry if they move from Italy. This lack of an independent dental profession in Italy confronted interested parties with a grave problem, finally resolved by the unprecedented order by an international government authority to a sovereign national government calling upon it to create a new profession. The review of how Italy came to receive such an unprecedented order from an international governmental agency and of its effects upon the dental profession in Europe highlights the virtually unique character of the event itself in the history of professions. The attainment of professional status, of an 807

assured monopoly of practice, of specialized education, of regulated entry to practice, and of public recognition normally occurs. if it does at all, within the bounds of the political and professional systems of individual sovereign nations. Contentious e&changes among associations of practitioners, groups of specialists, educators, government administrators and legislators, and members of the public, often characterise the process. When an external governmental entity calls for modification of traditional modes of entry, of practice and of regulation of a profession, this must bring such exchanges to new heights that lack precedents in national experience. Networks in contact on matters related to professions then must expand to international spheres. Seeking to improve the migration rights of individuals from the member-states, the Council of Ministers, the key policy-making body of the Common Market, approved Dental Directives in June 1978. Medicine. nursing and law (in part) were the first to be covered by such Directives; veterinary surgeons were to follow in late 1978, midwives in 1979; and architecture, accounting, pharmacy and engineering as well as others are now being considered [2]. Italian dentistry constituted a special problem for the Common Market. A dental profession separate from medicine does not exist and the flow of individuals without discriminatory treatment into and from that country thereby confronts a lack of institutionally-defined roles. As one British dental leader noted: “United Kingdom dentists cannot practice in Italy except as quacks and hirelings” [3]. Italian dentists, all of whom are medical doctors, are not qualified to practice in other countries of the Common Market where qualification in a dental school is obligatory, nor can graduates from schools in the other countries practice dentistry in Italy in the absence of a medical

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LOUISH.

qualification. This slowed preparation of the Dental Directives and led finally to the unheralded order af the Common Market to Italy to create a separate profession of dentistry. The analysis undertaken here covers three elements: (I) the efforts of medical-dentists within Italy to reach consensus concerning a possible internal move toward creation of a separate dental specialty, (2) the actions of the international committee of dental associations in trying to deal with the problem of Italy through communication with the Italian medical profession and with the groups of medical-dentists within the medical profession. and (3) the actions of Community bodies to cope with the problem of Italian dentists. In all of these, reliance on political and governmental authority is extensive and interaction of profession and political bodies can be shown to be fundamental to the understanding of the development of professions in the modern world. This analysis forms part of a larger, cross-national study of relations between professions and public authority in the 9 member-nations of the European Economic Community or Common Market. The underlying approach stresses the use of multiple informants, either participants in the events reviewed or observers in structural positions where information about those events would normally flow. Common Market officials, government administrators and negotiators, educators and association leaders constitute the sources relied upon in this undertaking. The reconstructions of discussions and negotiations come from accounts by these key informants, supplemented by review of published reports and articles, correspondence, memoranda, draft documents and other ephemeral materials. Protracted and complicated encounters embroiled various components of the medical and dental professions, both domestic and international, of national governments, and of an international public authority in extensive communication. Once the Common Market’s Commission issued Draft Directives for dentists, various national bodies, governmental and nongovernmental, prepared evaluations and made amending proposals then placed into international discussions. Those also are used in the analysis. The fundamental matter at issue concerns the dispute, arising within the context of international authority, concerning who is qualified to provide a specified kind of vital professional service. Italy alone of the 9 member-nations of the Common Market restricts the right to provide dental care to medical practitioners. This could not normally be problematic unless large numbers of qualified migrants existed, or unless. as occurred here, an international body began to wield authority about the qualifications in various nations. That intervention constitutes a novel stimulus to change, as government authority, association responsibility and educational controls normally diverge in different countries. This provides an intriguing example of the relations between professions and government in both a national and an international context. The interplay at a national level has been well interpreted by Gilb [4], and Johnson and Caygill [S] have attempted a similar analysis of the network of nations in the British Commonwealth. The Italian dentists and the

ORZACK

Common Market present a case of international authority impinging upon a sovereign nation’s prerogatives to initiate and control, if desired. a sphere of work activities usually conceived as parochial to a domain, A professional specialty. a dominant profession, sovereign governments, multi-national professional interests, and an international authority participated in formation of a new dimension of public policy. Neither qualifications nor the scope of professional practice in various countries had commonly been on agendas of discussion at meetings of these bodies. These topics for the most part lay beyond their experience. Forced to cope with those topics by the Common Market’s emergent concerns, both government and professional bodies took steps to initiate proposals and to respond to those of others [6]_ NATIONAL

PATTERNS

AND SPECIALIZATION

Specialist migration. foreign experience of students and practitioners. and imperialist dominions have occasionally led to duplication or imitation of professional structures in distant areas of the world. Thus. Solomons [7J notes that “The accountancy professions of the English-speaking world have all sprung from that of Britain. Some of the first practising accountants in the United States had started their careers in Britain and naturally the professions in Canada and Australia at first looked to Britain for their model”. Terence J. Johnson and Marjorie Caygill [S] refer to “. . an international professional community” which has *‘ . emerged from [the] . , developing network of relationships which has linked professional occupations throughout the British Commonwealth for well over a century; a ‘web of affiliations’ which until recent years has spread outwards from the professional associations and educational institutions of Britain”. Drastic changes in the structures of professions have often followed revolutionary alterations of government and other social institutions as well as territorial acquisitions by military conquest or treaty. Various examples of imperialistic expansion and of educationat dependence exist in the Third World where elements of older forms of professions. laid down by displaced traditional authorities, have been often supplanted. The more recent expulsion or departure of established professionals from Third World countries has in many instances forced newer governments to re-assess professional institutions and make them more appropriate to existing cultural and structural conditions. Aside from the military and ministerial professions and instances of colonial imposition. professional systems in developed nations have largely flowered or withered within their borders. Italy shed the yokes of foreign control in the last century when national unification occurred. The 1870 acquisition of Rome from papal authority by Italian troops marked the end of a lengthy amalgamation of hitherto independent sovereignties and foreign enclaves and the creation of the dominion of the Kingdom of Italy covering the peninsula on the southern coast of Europe. The firming of government. educational, economic and social institutions particu-

Italian denttstry and the E.E.C. lar to Italy followed. Its dental practitioners. members of a key elite in the advanced industrial society Italy has now become. are currently educated as medical doctors who may engage in dental practice immediately upon graduation or complete a later optional program of specialization. Italy constitutes a unique exception to the earlier separation of medicine and dentistry common in most other countries including those of the European Economic Community or Common Market. The general pattern was formulated by Guerini [9] of the who wrote that *I.. up to the beginning eighteenth century. dentistry was. in great part, considered one with medicine and surgery in general.. The definite separation between the science and art of dentistry and general medicine and surgery.. could not fail to take place”. How parallelism, independent development, or direct institutional linkages account for the general autonomy of dentistry from medicine remains beyond the province of this study. However, Hein states, “the most predominant track throughout the world is for dental schools to be separate entities.. with their educational programs designed to qualify the student to enter directly into general dental practice upon graduation”. He adds that where dentistry is a sub-specialty of medicine this method “ does not lend itself to the production of large numbers of dentists and as a consequence of this.. there has been a tendency for a lesser trained second level of dentist. who is more of a technician, to arise beneath the stomatologist” [lo], a title common to graduates of such programs. ITALIAN

DENTAL

PRACTICE AND THE

E.E.C. DIRECI-IVES

In Italy. the present tice are as follows:

systems

of education

and prac-

dentistry may be practised only by holders of the diploma of medicine and there is as yet no obligatory further training for those wishing to practice dentistry. To obtain the ‘Diploma di Laurea in Medicina e Chirurgia’ (doctorate of medicme) candidates must hold the ‘Diploma di Scuele media superiore’ (certificate in intermediate secondary educatton). follow a university course of 6 years’ duration in a Faculty of Medicine, and take the ‘Esame di Stato’ (State examination) which gives them the right to appear in the Medical Register and to practise medicine and dentistry [Il. 123. In 1976, some So00 individuals in Italy engaged in both a general medical practice and a dental practice, while about 4000 holders of the medical diploma practiced dentistry exclusively. A further 8000 medically educated doctors had voluntarily attended advanced programs of dental education lasting 2 or 3 years and obtained the ‘Diploma di Specialists in Odontoiatria e Protesi Dentaria’ which permitted them alone the right to adopt the title of ‘Medicodentista Specialista’ [ 131. The E.E.C. Council of Ministers approved Dental Directives in June 1978 to provide the right of individual dentists in member-nations to establish practice on a permanent basis. to offer services temporarily, and to have their diplomas recognized within the entire Common Market domain [14]. Nationals of the member-states educated at universities within

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them can enjoy such rights thereby enabling them to migrate without facing discriminatory treatment. The Directives provided for the development of a common basic curriculum of 5 years duration at the university .level and the creation of a consultative committee on training. This committee will consist of 3 experts from each member-state. (1) a practicing dentist; (2) a faculty expert from the universities or comparable institutions; and (3) a representative from the ‘competent authorities’ of the member-states. The last would presumably be nominated by the various Ministries of Health. This Advisory Committee would work to ensure ‘comparably demanding standard’ for initial and specialized training. The Directives supplied a list of titles of dentists recognized in each country. specified the particular diplomas and other evidence of formal qualifications in dentistry awarded by universities, examiners, and government bodies, called for registration access, permitted the creation of information centers to supply information on health and social security laws as well as professional ethics, and detailed training requirements leading to qualification extending over 5 years of full-time theoretical and practical instruction. All member-states were called upon to “ensure that dental surgeons shall generally be entitled to take up and pursue activities involving the prevention, diagnosis and treatment of anomalies and diseases of the teeth, mouth, jaws and associated tissues in accordance with the regulatory provisions and the rules of professional conduct governing the profession. ” Finally, the Committee of Senior Officials on Public Health created in 1975 for medical doctors received added authority to oversee implementation of these Directives for Dentists. The Council authorized a maximum period of 6 years for Italy to comply to the standards of these Directives. By that time, Italy is expected to create a new educational program leading to a dental diploma as well as a certifying body, thereby establishing an independent profession, dentistry. As a staff member of the Council of Ministers stated, such Directives 6‘ are international law which can be enforced by a Court of Justice” [lS]. Thus, within a 6-year period ending in 1985, Italy is expected to make dentistry into a new, separate profession and thereby permit both the migration to Italy of dentists from the other member-nations with rights of practice and the emigration of Italian dentists with similar rights to other nations of the Common Market. THE CREATION

OF DENTISTRY

The development of professions is part of the advancing divisions of labor, with changes in technology, specialization, authority and the growth of personal expectations and definitions of individual needs that require reliance upon the competency and abilities of others. Dentistry is an unusual speciality among such professions because of its late development along independent lines. Carr-Saunders notes. that “Dentistry is. in fact. remarkable among professions for the relatively very long interval which elapsed between the development of the art and the organization and recognition of its practitioners” [ 163. The Royal College of Surgeons awarded the first

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LOUIS H. ORZACK

license in dental surgery in 1859. In 1878, The British Medical Jmtrnal asserted however that “Medicine is a profession; dentistry is largely a business”. The 1878 Dentists Act placed administrative authority in the hands of the General Medical Council and CarrSaunders states this was a ” . relic of the subjection of the dental orofession to the medical orofession”. A dental registe; was finally set up by the Act of 1878 hut was still under the authority of the General Medical Council. Registration was a-prerequisite for public use of the term ‘dentist’ or ‘dental practitioner’. Unregistered and presumably unqualified practitioners continued, however, using titles such as ‘dental expert’, ‘dental cons&ant or ‘dental operator’. CarrSaunders notes that while the Dentists Act of 1878 did create a profession, continued practice by unregistered persons made it a sham. By 1919, the dental register included 5524 names: between 8000 and 9GQO unqualified and unregistered persons continued to provide some form of dental care in the United Kingdom including persons such as butchers and blacksmiths. Recognition of widespread abuses led to the Dentists Act of 1921. Its provisions closed the profession. states Carr-Saunders. The practice of dentistry required registration, except for medical practitioners and for emergency tooth extraction by registered chemists (pharmacists). Diplomas by a recognized body were required, while some already practicing were admitted directly to the register. The Act further created a Dental Board subordinant for discipline to the General Medical Council and responsible to it for its regulations. By 1933. 14,OCOwere registered, of which only half were educationally qualified. The others were admitted under statutory exemptions and. states Carr-Saunders. found professional ideals ‘alien‘ and continued to advertise and to sell. Abandonment of an earlier market-place orientation came late in Britain. Howe observes: In just over a century, dentistry has been transformed from a craft plagued by quackery and advertisement. into a self governing profession which has the privilege of maintaining its own standards of practice and education. One hundred years ago. the majority of practitioners were trained by apprenticeship, whilst nowadays new entrants to the profession train in dental schools which are part of a university and in most cases obtain a university degree ct73.

A General Dental Council was created in 1956 and thereby *‘ . . the profession achieved free self-government” [18]. Yet, Richards comments that dentistry has low status in Britain because of the lengthy reliance on ‘traditional dentistry’ and the long-standing subservience to medicine [19]. Moore describes dentistry in the United States as ‘&.. a controlled medical specialty rather than an independent profession. a profession not conspicuous for its prestige among either professionals or the laity” [20]. Its current variability in structure in various national settings presents some further support for reserved judgements about its stature. These derive from awareness of diversities in dental care delivery and public concern about dental services. Cohen’s analyses [213 support this as well as Schoen’s observations that the practice of “. dentistry or health

care in general is related to the politics and the economy of the country.. . There are countries with political and economic systems not terribly different from [the United States] . . . that have different health care systems” [22]. The delivery of dental care in Italy provides a telling example of a distinct system confronting the prospect of change. DENTISTRY

IN ITALY

AND

IN EUROPE

The characteristics of Italian practice are complex. A major problem of dental services concerns technicians who provide dental care. One medical-dentist described the situation as follows: The general physician has a request from the dental technician , The dental technician practices dentistry and the physician writes. the prescription: they work together. The general physician does not know anything about dentistry: the technician knows just a little bit about dentistry from a technological point of view.. Practically. the technicians do everything.. . A lot of dentistry in Italy. many. many thousands of so-caped dental technicians, don’t do work in laboratories any more. They do work in the mouth. This is our problem [23].

An informed appraisal of a prevalent link of technician and medical doctor was supplied by another informant, currently a candidate for an advanced specialization diploma: Some dental technicians work by themselves.

More than 50”, or more of all persons practising dentistry are technicians.. They pull teeth and do prosthetics. They do bad cavities, make extractions and prosthetics. There are many illegal. It is not allowed, It is illegal, but there are many people without degree.. What usualiy happens is there is one true dentist. but he has one or two technicians working. and he writes his name out on the door. but the other people are worktnp there [24].

This problem of dental technicians providing dental services largely without supervision by medical doctors or specialized medical-dentists derives in part from the kind of education in dental care provided to students at the Italian medical schools. One recent graduate of medical school who plans to become a specialist in dentistry described the scope of dental education in medical school as follows: In six years of medtcine. we do only one examination in dentistry rn the fifth year. The only practice proof is just to show the teacher which instrument you use if you want to extract a molar or an incisor or the third moiar. It is the only practice examination: you don’t do an extractton, you must show the teacher which instrument you use. We don’t practice, it is all theoretical [25].

Another described the extent of dental education in the following terms: The general doctor knows grossly how to take a tooth out. but he knows nothing, because all the study of thrs at the university takes 1 week, f0 days. IS days of study in the stx years. A very small examinatton 1261.

Given this limited background. the general doctors may call upon dental technicians to supply added knowledge. Given the failure of punitive authority to control technicians and the open access by medical doctors to

Italian

the practice of dentistry without extensive preparation. it was not surprising that Committee of Dental Practitioners of could summarize the situation in Italy follows:

denttstry

educational the Liaison the E.E.C. in 1963 as

It would appear that the time has come for Italy to mtroduce odonto-stomotological education and thus align herself with the majority of other countrtes of equal development. by institutmg for practitioners of odonto-stomatology a special and compulsory system of education which would permit the recruitment of a sufficient number of qualified practitioners. This. furthermore, would put an end to the scandalous situation in Italy where the illegal practice of dental techmcrans is detrimental to public health--this state of affairs has, moreover. practically disappeared in the whole of the other five E.E.C. countries

[?7]. Internal opposition to reform has continued within the ranks of medical doctors engaged in dental practice. “One obstacle is the so-called practitioner who is the illegal dentist”. Another source of resistance arose within the ranks of medical-dentists themselves. In the past. we were split. There was a small group that wanted to improve. a very small group. mainly practitioners. not from the University. All the University people were against the change. Professor B. is leader of us today. He did work in this dtrection always [28].

Direct opposition for reform of education and practice continues from some medical doctors. Their views were described as based on a generalized opposition to change, personal and professional distrust of the competency of graduates of the proposed new curricula. and pride in medicine’s accomplishments and standing. Such perspectives have largely been overcome at least within the ranks of two independent groups of medical-dentists. the Associazione Medici Dentisti Italiana (AMDI) and the Union for Reform of Italian Odontoiatrico (URIO). A proposal to legitimate the practice of dentistry by dental technicians, the ‘traditional dentists’ characterized by AMDI as ‘illegal dentists’, has distressed the proponents of reform in dental education and practice. One described this as follows: Some of the politicians are also for a law to give recognition to the so-called dental technicians. They try to get a special course for just two years that would make a degree for just prosthetics. They say. they have been doing this for many. many years. illegally, and the results are good enough.. If something like this happens to Italy. this is a real danger and can spread to other countries. including the United States [29]. This effort to make legitimate the open entry of technicians without university diplomas to the dental field is considered threatening. If such legislation were passed, the activities of technicians would be nominally and legally restricted to prosthetics. Representatives of AMDI consider such a proposition as likely to constitute a distinct threat to the future of dentistry. They believe that the technicians would in fact continue to work independently or largely without professional control, Dental care in Italy can therefore be described as distinctive from that in other West European member-nations of the Common Market. The medical \\\I I’fl4 ,

and the E.E.C.

811

dominance of the practice of dentistry. the presence of many technicians who work in a fully independent fashion or at most with nominal supervision. and the insufficiency of dental education in the medical curricula contrast starkly with the features of dental services in other countries. Outside Italy. the bulk of dental care is furnished by graduates of dental curricula. although national legislation may permit medical doctors to practice dentistry. Dental technicians in these countries manufacture devices prescribed and fitted exclusively by dentists [30]. At the same time, exceptions to a dentists’ monopoly do exist in Common Market countries as legally-sanctioned boundaries between medical doctors and physicians vary somewhat. In France, for example, 24,tXlO dental surgeons-chirurgien-dentiste-co-exist with about 1000 stomatologists, the latter possessing a diploma in medicine and, possibly, a state diploma in dental surgery or a certificate of special studies in stomatology and/or in surgery. Until recently, the chirurgien-dentistes were limited to certain drugs and procedures. Belgian dentists with a special license number about 2300 of which 460 are also medical doctors or stomatologists, in addition to some 300 older dent&es who completed a nowabolished 3-year program in a non-university dental school, and about 100 doctors of medicine who practice dentistry. The use of general anesthesia is limited to the medically-educated stomatologists. Medical stomatologists of France and Belgium thus have a somewhat wider range of practice than dentists and further, at least until recently, enjoyed a higher scale of free from social security systems [31]. A final indication of variation in the dentists’ activities concerns the approximately 32,000 Zahnlrzte in the Federal Republic of Germany. About 23,000 have university training and diplomas for a doctorate in dental medicine, while an additional 9000 persons with backgrounds as dental technicians also practice as Zahnlrzte after various combinations of apprenticeships, supplementary training, clinical practice, and state and professional examinations [32].

THE COMMON MARKET PROBLEMS WITH DENTISTR\

Pressing issues confronted the delineation activities in the Common Market countries. cluded the following:

of dental These in-

1. The sromatological problem: does dentistry stand as a constituent specialty of medicine or is it a separate specialty with its own educational system. a practice distinct from if related to medicine, and modes of control apart from those of medicine? Howe summarized this by noting that “stomatology is recognized as a specialty in France, Belgium and Italy.. . In all three countries. most stomatologists are wholly engaged in general dental practice”. The participants in this field created a “Monospecialist Committee for Stomatology”, recognized within the Union Europeenne des Medecins Specialistes (U.E.M.S.). the coordinating body for such commitmittees of medical specialists in Common Market countries. In 1972, the Committee sought a name change to ‘Stomatology and Maxilla-Facial Surgery”.

LOUISH.

812

thus appearing to claim medical domination of the broadest possible scope of dental surgery and to strengthen its links with general medical surgery [33]. The British Dental Association joined with the Mono-Specialist Committee of Plastic Surgeons in the making of a vigorous and successful objection to that proposal. On behalf of its constituents, the Plastic Surgeons group pointed out that much maxillofacial surgery was not recognized by any European country [34]. Acting in concert with the British Medical Association which arranged for the presence at U.E.M.S. meetings of individuals who were both medically and dentally qualified, the British Dental Association argued that consultant dental surgeons in the United Kingdom were entirely dentally qualified and further had extensive training in maxillo-facial surgery. In 1972 or 1973, British dental interests had nominated a non-medical consultant for their representative to the Monospecialist Committee of Stomatologists. Upon that Committee’s refusal to accept the nominated person as a member, the British Medical Association refused their own seats on the Committee. The B.M.A. took the issue to the Council of Direction of U.E.M.S. and the Council undertook a study of the issue. The final resolution after much study and negotiation ending in October 1974 was agreement on the distinction between maxilla-facial surgery as a medical specialty and stomatology or oral surgery as a specialty open to either the dentally or medically qualfied person [35]. The Monospecialist Committee for Stomatology sought as well to have Stomatology recognized as a medical specialty in the Medical Directives of the Common Market. If Stomatology were so viewed, and shortly thereafter Dental Directives were to define the activities appropriate for practitioners affected in turn by them, then “there would be ‘one field of activity’, namely general dental practice, which would have two entirely different ‘portals of entry’ governed by entirely different sets of rules. A unique situation in the EEC” [36]. Within Britain. observed Howe, consultant dental surgeons who are either medically or dentally qualified “. wish to be treated as one group”. 2. The Italian problem: how could the Common Market confront the Italian pattern of dentistry as a field of medicine and reconcile this with the separate field of dentistry typical in the other member-nations? The 1963 report by representatives cluded that

of the Liaison of 5 national

Committee, signed associations, con-

the Italian practitioners.. could. m theory and with the support of the Government of their country. obstruct the spirit of the Treaty of Rome by denying the right of establishment to practitioners from the other five co-signatory countrtes who are not doctors of medicine. Certain indications permit us 10 affirm that the Assoclazlone Medical Dentisti Italiani (A.M.D.I.) intends to deny the ‘Chirurgiens-Dentaire’. ‘Zahnlrzte’. ‘Tandartsen’. ‘Licenck en Science Dentaire’ and ‘Docteurs en Mtdecme Dentaire’ the right of establishment in Italy [37]. Acting earlier upon such assumptions. AMDI had refused to join the ‘Liaison Committee of Dental Practitioners’ upon its formation in 1960 [38].

ORZACK

After more than a decade of isolation from other dental groups representative of practitioners in the various Common Market nations, AMDI was persuaded to join the Liaison Committee for Dentistry in the E.E.C. Countries in 1973. As a body representative of medical dentists in Italy. AMDI has come to espouse reform in dental education and practice. So does the Union for Reform of Italian Odontoiatrico (URIO). Supporters of change. they confront the major problem: the prospective loss of affiliation with the universities’ medical faculties and of the medical doctors’ place in society. Many committed to dentistry have preferred the mantle of medicine to the risks they anticipated if the garb of dentistry were acquired from abroad. The groups differ [24] in membership base and in specific conceptions of needed reforms. AMDI includes medical-dental specialists, that is, those medical doctors who voluntarily went on to acquire specialist training in dentistry, as well as those medical doctors who certify their practice is limited to dentistry. The specialists constitute the majority. URIO draws mainly from younger segments of the field. Both organizations urge the creation of university-level dental education separate from medicine but diverge on key details. AMDI in recent years has called for government action to create joint programs of medical-dental education for the first 2 years of university education. For those seeking to become dentists, this would be followed by 4 years of specialized dental education with extensive scientific education and dental practice. URIO prefers separation of dental education from medical education at the very outset of university training. Despite these differences. both organizations express the hope that the government will in due course establish a mandatory system of registration for dentists separate from that for medical doctors and prevent the latter from entering the practice of dentistry. Another approach toward emergence of a separate dental role had previously been discarded by AMDI in the face of resistance from government and from the medical profession. Under that arrangement, the government would establish a new and restricted title within medicine for the holders of certificates that showed specialization of practice in dentistry. AMDI’s acceptance of creation of a new title for dentists, a new education system, and a new registration mechanism represented ideas quite acceptable to other national associations of dental practitioners. permitted its membership in the Liaison Committee after years of isolation. and was a distinctive step before other vital action could be taken within the official Common Market institutions. AMDI’s reversal of views from support for a governmentally-recognized dental specialty within medicine to support for a non-medically qualified dental specialty occurred in the face of substantial opposition within the medical professlon. Many dental practitioners qualified exclusively through medical studies exerted ‘* powerful influence in the political sphere”. especially In the 1960’s [39]. As the then Secretary of the British Dental Association was soon to observe. A steadily growing favour of a separate

body of opmlon dental professlon

[in Italy was] in and the establish-

Italian

dentistry

ment of a full dental curriculum m the universities. and it was thought Cm 197C-711 that the representative of the Italian Government on the Council of Ministers might have been able to cast his vote with those of his 5 colleagues in favour of the directives and recommendations c401.

This did not occur. At the level of government action, in late 1970 the Italian government became more hesitant about any change in its own system when another membernation of the Common Market, Luxembourg, proposed a 5-year program of medical education coupled with two further years for dental study [41]. About this time also the preliminary negotiations for the later accession to the European Communities of the United Kingdom, Denmark and Ireland in 1973 were underway. and consideration of such matters as Draft Directives for dentists and for other specialties was laid aside by Community and government personnel. As more intensive discussions of the Draft Directives for dentists resumed at professional and governmental levels, both national and international, the key site was the Committee of Permanent Representatives. COREPER, a subsidiary unit of the E.E.C. Council of Ministers. COREPER had been given the task of moving the Drafts closer to a final text in preparation for any subsequent review and a vote at the political level by the Council of Ministers itself. In any event, the Draft texts were at least technically and directly away from the hands and scrutiny of national and international professional groups. At the COREPER stage of consideration, and by 1973, the Italian government representative had accepted a two-fold ‘compromise arrangement’. First, they supported the recommendation that Italy would introduce a distinctive dental education course as soon as possible. Second, Italy approved clauses in the Draft Directives for ‘transitional arrangements’. These were described as follows: These

were to the effect that any dentist who wanted to practice in Italy who came from another state with a dental qualification from another state had to do a two year course in medicine and surgery in Italy without examinatIon. Any Italian who wanted to go and practice in any other member state had to do a two year course in dental subjects in the host member state. And in those host member states in which you could not practice dentistry by virtue of being on the medical register. they also had to do an examination [42].

Objections to such provisions were voiced by the new British and Danish representatives to the Community along with reservations about other aspects of the Draft. The position of the specialties of oral surgery and orthodontics as well as the apparent lack of provisions to evaluate the quality of the educational curricula delineated in the Draft also caused concern. The Italian ‘problem’ and these other matters in combination held up approval of the Directives by Council of Ministers. Further deliberation by COREPER and re-consideration by member governments finally led to the Council once again placing the Draft Dental Directives on its agenda for action. The delay ended only when the Italian Government finally was persuaded as action was started in the Council. As one staff member at the Council observed.

and the E.E.C.

813

Up to the point that we started looking at the Directive in the Council. many people said there’s no point in doing this because the Italians have not got a dental profession. We started looking at it in the Council and the ltahans with really good community spirit set about solving the problem. Had we never started looking at this problem in the Council, the Italians would never have done anything. The Italians only took action once we started in the Council. The Commission Directives did not move them. Once it came to the Council., the political process started [43].

The Directives for Dentists passed by the E.E.C. Council of Ministers in July 1978 recognized the basic dental diplomas of the 8 nations where those diplomas were awarded, identified the titles under which practitioners worked, and identified orthodontics and oral surgery as advanced specialities in certain member countries. For the Italian situation, the Directives provided a 6-year additional period to permit compliance by the creation of a new profession. dentistry, “. . under a title other than doctor’*. of a specific system of training, and of structures appropriate for ‘this new profession’ such as a ‘council. for example’. For all countries. the Directives provided a definition of activities for members of the dental profession. This referred to needed knowledge of basic sciences and of the characteristics of healthy and sick persons and further specified the following essential competence of the practitioner: adequate knowledge of the structure and funcllon of the teeth. mouth. jaws and associated tissues. both health! and diseased. and their relationship to the general XI~IC of health and to the physical and social Bell-brmg of thr patient: adequate knowledge of clinical Jlsclpllncs .~nd methods. providing the dentist with ;I cohcrcnt plcturr ,)f anomalies. lesions and diseases of the tc~lh. mouth. J,IN~ and associated tissues and of pre\rntl\c. d~a~ncrxt~c ;IIIJ therapeutic dentistry: suitable clinical experience under appropriate supervision. This training shall providr the skills nccc’>*ar! LV carrying out all activities involving thr prc\cntt<>n. diag-

nosis and treatment of anomalies and dlscascs mouth. Jaws and associated tissues [44]_

of the tc’L‘Ih.

This broad and ambitious formulation to permit the migration of dentists in Europe provided a clear challenge to Italy. its medical-dentists. its other medical doctors and its government. How would the challenge be met? How will the Italians ultimately come to terms with the proposals in the Directives?

DEADLINE

OF THE DIRECTIVES ITALY’S RESPONSE

AND

With Italy designated as the exception in the Directives and with elimination of its medical control of dental care to occur in 6 years. the task was now for the government of Italy to create a new profession. The medical-dentists had failed in their earlier efforts. prior to the Directives, to continue dental care as the prerogative of medical doctors. The thrust by some medical doctors toward a voluntary dental specialization had been undertaken some time ago, first with a 2-year course and then with 3, after award of the medical degree. Their identification as medical doctors by education and commitment was important

814

LOUISH.

and key leaders held back their support of such thorough going specialization that could lead to a departure from the field of medicine. Many medical doctors resisted moves toward dental specialization. content with their own work in furnishing dental care or with their incomes from joint or nominal practices with dental technicians. Dental technicians who practiced ‘traditional dentistry’ or ‘illegal dentistry’ acted to forestall the creation of a dental specialist who would first compete and then seek forceful, political means to drive out these marginal practitioners. By 1978, AMDI supported creation of a new profession. Having recently consolidated its own views and overcome its internal differences, the AMDI now faced its repeated failures in the past to force its own government to initiate the creation of a non-medical dental curriculum and field of practice. Repeated efforts to persuade the government’s Ministry of Education and other officials to take steps to reform university programs and conditions of practice did not succeed. Further, efforts to persuade university and medical faculty leaders to initiate reform from within had. not surprisingly, failed in the face of repeated efforts [45]. The non-responsiveness of Italian institutions to the AMDI’s efforts to reform the systems of dental education and service delivery required a new departure and AMDI now sought change through pressure from an external organization having governmental authority, the Common Market. The mandates of the Dental Directives for Italy to create a new profession would not by themselves be sufficient to bring about the new structures that AMDI espoused. The Directives provided Italy with a 6-year limit to begin to provide the rights of professionals to migrate freely. This would require an immediate start for the standard 6-year university program. How would that be implemented? How soon? By whom? The issue is still open. Consensus among medical and dental interests had been slow in coming, but in recent years, despite argument about whether the first year or the first 2 years of dental education should be organized jointly with medical education, consensus among practitioners and educators had been attained. AMDI has come to represent itself as the foremost advocate of independence of dentists and of dental education, and the Italian Medical Association itself has come to accept this approach. The strategy for reform could be exerted on many levels: at the universities themselves where medical faculties are deeply entrenched. preventing internal change; at the Ministry of Health where previous proposals have foundered despite favorable appraisals during discussion; and at the Italian Parliament where the several political parties and interests have not united on this, as well as other issues. The stage of implementation envisaged in 1978 for Italy was outlined by one active in the Liaison Committee for Dentistry as follows: The Italians have Introduced [a proposal for]. special dental education. It‘s commg up now. There is a proposed law brought up in the Italian Parliament and 1 think it is well on Its way but they have not yet started to have thrs bpeclality. It is on its way [46].

This approach has apparently not worked successThe remaining channel for reform would be at the highest level of government. the President of the fully.

ORZACK

Republic of Italy. If he could be persuaded to intercede by direct submission of a proposed law to the Parliament. legislative reform of dental education and practice could finally begin. This is the current strategy being sought by AMDI and its collaborators. In Spring 1979, AMDI along with various medicaldental educators and representatives of the Italian Medical Association successfully reached agreement to seek the intercession of the President for this purpose. So, the implementation of the Dental Directives within Italy which clearly involves drastic changes in education and practice now depends on whether the President of the Republic can be induced to introduce legislation in the parliament with special status to facilitate quick action in that legislative body. The time is now critical. The 6 years of education required for the new dental practitioner must begin in Fall 1979 so as to yield its graduates in 1984 or 1985. If Italy does not meet the deadline, either further delay will have to be sought while migration of specialists to and from Italy will remain blocked. or the Common Market might take other steps to deal with such intransigence. Having agreed to Council deliberations with other community leaders on the text of the Directives. the Italian government is now faced with the need to create a new profession within 6 years. CONCLUSIONS

The complexities of single professions in different nations have not commonly been compared [47]. When the cross-national study of professions is undertaken, intricate relations between professions and governmental institutions can become more clear. Similar gains come from inter-professional comparisons within single nations. Dynamic changes in structures of professions and in governmental authority constantly occur. Common Market undertaking of the harmonization of professions in Western Europe supports the additional level of analysis of change and stability on an international scale in the arenas of the professions. Examination of the single profession of dentistry or of other professions raises questions about the timing of change. Why were certain professions-medicine. nursing, veterinary surgery. dentistry. midwifery, and. in part, law-the first to undergo the process of planned change on an international scale’! Why have mainly health professions led the way‘? The other fields which await Common Market action include certain health professionals-pharmacists. opticians-as well as accountants. architects. engineers and lawyers. Are these less susceptible to international harmonization because of greater diversities in their fundamental bodies of knowledge. systems of education. and scopes of practice’? Do higher levels of pre-existing exchanges of students. educators and practitioners lead to broader unanimity of approach and of preparation among certain professions, thus rendering them more susceptible to harmonization efforts by international governmental bodies‘? The unusual organization of dental care in Italy made possible a rare example of an attempt by an international governmental authority to intrude in the internal affairs of a sovereign member nation. This

Italian dentistry and he E.E.C. arises as the Common Market tries to harmonize professional education and practice so as to facilitate the easier migration of citizens of the member countries within the broad expanse of Western Europe with full rights to engage in the practice of their specialties. Since the institutionalization of professions within single nations is almost universely an internal matter. the European Economic Community’s actions concerning professions in Western Europe introduce by their very occurrence some new features into the environments where public policy concerning professions is formulated. Educational interests, practitioner groups. and government units of individual nations have been joined by international liaison committees of national professional associations and by an inter-governmental authority claiming some sovereignty for the nature of professional organization [48]. In Europe. this constellation points to a liberalization of national barriers to the free movement of professionals. A similar thrust has not developed in the United States where movement across state boundaries for those in licensed professions is substantially restricted. Concern about the ‘foreign graduate’ meeting domestic standards and competing with professionals educated within the country support arguments for continued insularity. Harmonization among European countries acting in concert is not matched by harmonization within the United States or between the United States and other parts of the world. Yet, the ‘crisis of professional authority’ as Bourricaud [49] terms it, may merely be taking different forms with the growing envelopment of national professional systems in Europe by the cross-national authority of the Common Market and with trends toward consumerism and more intensive regulation at state and federal levels in the United States. REFERENCES 1. European

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iv rhr Ninr

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815

hc E.E.C.. p. 17. Brltlsh Dental Association. London. 1973 with 1978 amendments. and practice requirements a decade 12. =or education :arlier. see: Comitk de Liaison des Pratlciens de I’Art Dentaire de la C.E.E. Erudr sur I’Eyuiralencc de\ Dip‘cimra er /a Quulificarion Pr~fi.wionnr//r de.\ Praricivn.\ ir I’Arr Denruire dam le.\ Si\- Pal,.\ de la C.E.E. Con-

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2dCration Nationale des Syndicats Dentaires. Paris, 1963. Liaison Committee for Dentistry in the E.E.C. Countries. op. cu.. p. 18. Statutes of the various Common Market countries are contained in the volume of 4ppendicr.s prepared by the Liaison CommIttee for release with its study cited in reference 11. European Communities. Oficial Journal 21, L233. Council Directives of 25 July 1978, 78/687/EEC. 78/686/EEC. Brussels, 24 August 1978. Persona1 interview. 10 April 1978. Carr-Saunders A. M. and Wilson P. A. Thr Prokssions. p. 107. Frank Cass. London. 1964. CarrSaunders and Wilson’s account of dentistry’s development provides the basis for this and the subsequent paragraph. See their pp. 107-l 17. Howe G. L. The future of dentistrv in the British Isles. Br. Denr. J. 127. 208, 1969. Richards N. D. Dentistry in Great Britain: some sociologic perspectives. In Towurd A Socioloyy qf Denrisrr) (Edited by O’Shea R. M. and Cohen L. K.). p. 140. Special issue. Milhank mrml Fund Q. 49. 3. 1971. ibid.. pp. 140-141. Moore W. E. The Professiotw Role.\ and Rules. p. 179. Russell Sage Foundation. New York. 1970. Cohen L. K. Dental care delivery in seven nations. In Inrrrnurional Denral Care Delivery Dental Health Policies (Edited by

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in

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31

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Health

Policies,

p.

230.

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de

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