seeing this dentist for a long time, and although some of his treatments over the years were rather unpleasant, you feel that he has generally treated you well.
Now, I should point out—because your dentist might not—that craze lines are basically very, very small cracks in the enamel of your teeth, and what’s more, they’re almost always completely asymptomatic; many people have them and aren’t bothered by them in the least. So, in effect, it’s usually unnecessary to target craze lines with any kind of treatment.
LET ME GIVE you one real-life story from my friend Jim, the former vice president of a large dental company. Over the years, Jim has encountered his fair share of oddball dental cases, but one CAD/CAM story he told me was particularly horrible.
A few years after the CAD/CAM equipment came onto the market, one particular dentist in Missouri invested in the equipment, and from that point on he seemed to start looking at craze lines differently. “He wanted to crown everything,” Jim told me. “He was excited and enthusiastic to use his brand-new gadget, so he recommended that many of his patients improve their smiles, using, of course, his state-of-the-art CAD/CAM equipment.”
One of his patients was a young law student with asymptomatic craze lines; still, he recommended that she get a crown. The young woman complied, because she was used to listening to her dentist’s advice, but guess what? Because of the crown, her tooth became symptomatic and then died, forcing her to go in for a root canal. But wait, it gets worse. The root canal failed and had to be redone, and that second root canal failed as well. As a result, the woman had no choice but to undergo more complex and painful surgery. So what began as a treatment for harmless craze lines ultimately resulted in a lot of pain and financial cost for this young woman.
After the woman graduated from law school, she did her homework and realized that (surprise!) she’d never needed that crown in the first place. As you can imagine, she wasn’t thrilled by this, so she went after the dentist with a vengeance, took him to court, and won.
NOW, WHAT CAN we make of this tale? As we’ve already learned, people don’t need to be corrupt in order to act in problematic and sometimes damaging ways. Perfectly well-meaning people can get tripped up by the quirks of the human mind, make egregious mistakes, and still consider themselves to be good and moral. It’s safe to say that most dentists are competent, caring individuals who approach their work with the best of intentions. Yet, as it turns out, biased incentives can—and do—lead even the most upstanding professionals astray.
Think about it. When a dentist decides to purchase a new device, he no doubt believes it will help him better serve his patients. But it can also be an expensive venture. He wants to use it to improve patient care, but he also wants to recover his investment by charging his patients for using this wonderful new technology. So, consciously or not, he looks for ways to do so, and voila! The patient ends up with a crown—sometimes necessary, other times not.
To be clear, I don’t think dentists (or the vast majority of people, for that matter) carry out an explicit calculation of costs and benefits by weighing patients’ well-being against their own pockets and then deliberately choose their own self-interest over their patients’ best interest. Instead, I suspect that some dentists who purchase the CAD/CAM equipment are reacting to the fact that they have invested a great deal of money in the device and want to make the most of it. This information then colors the dentists’ professional judgment, leading them to make recommendations and decisions that are in their own self-interest rather than doing what is best for the patient.
You might think that instances like this, when a service provider is pulled in two directions (generally referred to as a conflict of interest), are rare. But the reality is that conflicts of interest influence our behavior in all kinds of places and, quite frequently, both professionally and personally.
Can I Tattoo Your Face?
Some time ago I ran smack into a rather strange conflict of interest. In this case I was the patient. As a young man in my midtwenties—about six or seven years after I was originally injured*—I went back to the hospital for a routine checkup. On that particular visit, I met with a few physicians, and they reviewed my case. Later, I met the head of the burn department, who seemed especially happy to see me.
“Dan, I have a fantastic new treatment for you!” he exclaimed. “You see, because you have thick, dark hair, when you shave, no matter how closely you try to shave, there will always be little black dots where your hair grows. But since the right side of your face is scarred, you don’t have any facial hair or small black dots on that side, making your face look asymmetrical.”
At that point, he launched into a short lecture on the importance of symmetry for aesthetic and social reasons. I knew how important symmetry was to him, because I was given a similar minilecture a few years earlier, when he convinced me to undergo a complex and lengthy operation in which he would take part of my scalp together with its blood supply and re-create the right half of my right eyebrow. (I’d undergone that complex twelve-hour operation and liked the results.)
Then came his proposal: “We have started tattooing little dots resembling stubble onto scarred faces much like yours, and our patients have been incredibly happy with the results.”
“That sounds interesting,” I said. “Can I talk to one of the patients that had this procedure?”
“Unfortunately you can’t—that would violate medical confidentiality,” he said. Instead, he showed me pictures of the patients—not of their whole faces, just the parts that were tattooed. And sure enough, it did look as though the scarred faces were covered with black stubblelike specks.
But then I thought of something. “What happens when I grow old and my hair turns gray?” I asked.
“Oh, that’s no problem,” he replied. “When that happens, we’ll just lighten up the tattoo with a laser.” Satisfied, he got up, adding “Come back tomorrow at nine. Just shave the left side of your face as you usually do, with the same closeness of shave that you like to keep, and I’ll tattoo the right side of your face to look the same. I guarantee that by noon, you’ll be happier and more attractive.”
I mulled over the possible treatment on my drive home and for the rest of the day. I also realized that in order to get the full benefit from this treatment, I would have to shave in exactly the same way for the rest of my life. I walked into the department head’s office the next morning and told him that I was not interested in the procedure.
I did not expect what came next. “What is wrong with you?” he growled. “Do you like looking unattractive? Do you derive some kind of strange pleasure from looking asymmetrical? Do women feel sorry for you and give you sympathy sex? I’m offering you a chance to fix yourself in a very simple and elegant way. Why not just take it and be grateful?”
“I don’t know,” I said. “I’m just uncomfortable with the idea. Let me think about it some more.”
You may find it hard to believe that the department head could be so aggressive and harsh, but I assure you
