Coronavirus Diary (59): Arguing About Dentistry Under Lockdown

I had an argument with a dentist the other day about a predictable issue: dentistry under lockdown. The argument turned into a predictable, pointless stalemate.

As a dentist, he was angry that his business was under lockdown. He’s been losing money, his patients are suffering and need medical attention, he knows how to protect himself and others against infectious disease because he’s done it for decades, so he saw no point in delay. Open up now, was his view. (Terminological point: I’ll assume throughout this post that dental procedures are a type of medical procedure.)

As someone worried about a second spike, and basically supportive of my own state government’s efforts at dealing with the pandemic, I was angry that he was so unreasonably angry. “Yes, I understand that you’re losing money, and that your patients are suffering,” I said to him. “Governments have a lot on their plates right now, and are doing their best to open up what can safely be opened up. You’re being more than a little arrogant in assuming that you can keep yourself and others safe from COVID-19 simply because you have experience running a dental practice. You don’t have experience running a dental practice during a pandemic; no one does.”

I see in retrospect that this was the wrong way to have a conversation. Anger produces a tendency to dig your heels in on what you know (or think you know) for certain, to insist on that and only on that, and to suppress the urge to venture into the unknown. What is known becomes the criterion of relevance; what is unknown becomes irrelevant. Hence the slip-sliding nature of “the issue” in so many angry conversations. The interlocutors are operating with different certainties, hence different conceptions of relevance.

Go back to what I said. Let me make it explicit and flesh it out a bit. It goes like this:

  1. I appreciate that businesses are losing money, which is a serious and significant loss.
  2. I appreciate that dental patients are suffering and need attention as soon as possible.
  3. Nonetheless, governments have many important aims to realize under duress and uncertainty.
  4. I live in New Jersey, so I’m most familiar with what New Jersey is doing, and I’m convinced that the Jersey state authorities are acting competently and in good faith. The most significant objection to their handling of COVID-19 concerns their handling of nursing homes, but this is a far more complicated issue than critics are making it out to be, and it doesn’t redound so clearly to the State’s discredit as those critics seem to think.
  5. New Jersey, at least, is making a good faith effort to re-open dentists’ offices. It’s worth noting that the American Dental Association shares the lockdown states’ concerns.
  6. There is no reason to think that a given dentist’s past experience with dealing with infectious disease in an office setting is sufficient to deal with infectious disease under conditions of pandemic.
  7. Hence anger at the presumptive “delay” in re-opening dentists’ offices is unreasonable.

I won’t belabor the strengths in my argument. I want to underscore the weaknesses I suppressed during the course of the argument.

One weakness becomes clear at steps (4) and (5): I was focusing on the case of New Jersey, which is where I live, and what I happen to know best. But New Jersey is somewhat unique. For one thing, the pandemic is uniquely severe here: New Jersey is the second-worst hit state after New York. Even within New Jersey, there are regional differences between north, central, and south Jersey: north was hit worse than central; north and central worse than south. What was true of north or central Jersey wasn’t necessarily true of where the dentist worked. Likewise, I was assuming that New Jersey’s approach to the pandemic has been reasonable and has involved good faith. But it’s possible that my assumptions about New Jersey are wrong, and even if right, it’s possible that what’s true of New Jersey state government doesn’t generalize to other state governments.

As it happened, the dentist said he practiced “in New York,” but I never asked exactly where in New York. “New York” could have meant Elmhurst, Queens (the epicenter of the pandemic), or could have meant Plattsburgh (hundreds of miles from the epicenter), or could have meant somewhere else. Different places face different sets of conditions. So I was ignoring regional differences that might have mattered. I was also presupposing that the complexity of the nursing home issue was enough to discount the possibility of incompetence or bad faith on the part of New Jersey’s state government. I still think I’m right about that, but I’m far from having mastered the issue.

A second weakness arises at step (6). I have no reason to think that a given dentist’s past experience with dealing with infectious disease in an office setting is sufficient to deal with infectious disease under conditions of pandemic. I mean, I’ve gone to the dentist for decades, and have worked in medical settings (doctor’s offices, hospitals). That seems like sufficient experience, doesn’t it? And surely my claim seems plausible enough from that sort of armchair. But the fact remains that it is a sort of armchair. I’m not a dentist. Moreover, I’m not that dentist. I never asked him about the precautions he actually used in his office. What I said was that I found his claim implausible. What I should have said that while I found it implausible, perhaps he could tell me why it was more plausible than I was in a position to see.

Now look at his argument in skeletal form. It’s worth noting that I find it harder to flesh out his arguments than mine, partly because I am not him, partly because I remain somewhat unsympathetic to his position. Any dentists reading might want to tell me what I may be missing. I’m probably not going to become a dentist by reading about dentistry online.

  1. My business is losing money, a significant loss.
  2. My patients are suffering, and need attention.
  3. I know how to protect myself and others against infection; I’ve done it for years.
  4. The government is delaying the re-opening of dentists’ offices without discernible reason.
  5. Hence anger is justified by dentists and their patients at states’ unreasonable delay.

I’ve already conceded that this argument has some significant strengths, but there are weaknesses here that my interlocutor was unwilling to deal with.

One subtle weakness concerns (2). In conducting the argument, the dentist gave the impression that many of his patients were suffering acutely from dental emergencies or emergency-like conditions. He provided no evidence for this claim, and I thought it impolite to demand substantiation (“Bullshit! How many emergencies? Count ’em, bitch!”). But it’s not obvious that it was true. Angry people have a tendency to exaggerate the merits of their case (and he was angrier than I was).

Granted, the larger issue isn’t settled by focusing pointillistically on the demographics or epidemiology of this particular dentist’s patients. But exaggeration would have undermined his credibility, and went undiscussed. The concept of “(dental) emergency” is a difficult one, but the dentist failed to mention that the treatment of dental emergencies was not banned under lockdown (at least not in New Jersey). Granted, certain emergency-like conditions that didn’t qualify as emergencies by some legalistic definition might have gone untreated. But the dentist failed to mention any of this complexity, and much of it was, though not conclusive, still relevant.

Another weakness, to my mind the biggest one, concerns (3): doing ordinary infection control for years isn’t evidence that you can do extraordinary infection control in any competent way. What I should have asked was whether the dentist would demand that his patients waive liability for contracting COVID-19 from dental work done at his office. More broadly speaking, though, what did the dentist think about liability issues?

Suppose that through a lapse on his part, or on the part of his staff, or on the part of a patient in his office, someone got COVID-19 and suffered serious harm from it. Would the dentist regard himself as morally responsible for it? Legally liable for it? How did he propose to handle the issue of contact tracing to determine the source and trajectory of the infection?

It’s of no use to throw up one’s hands and point to the insuperable epistemic difficulties involved here. Those epistemic difficulties are part of the reason for the lockdown in the first place. The lockdown is a prior restraint against epidemiological rights violations. It’s precisely because we lack the capacity to trace the harm done by this disease vector that things are locked down: once the virus is out there, if unchecked, it spreads exponentially. Given any plausible infection fatality rate, somewhere in that exponential spread, you will start to get mortality. Well before that, you will start to get serious morbidity. Those are all rights violations.

This disease vector can only be stopped by preventing actual transmission. But given the reality of asymptomatic transmission, actual transmission can only be stopped by preventing potential transmission. And the prevention of potential transmission requires limitations on human contact, including limitations that fall on people who will later be seen as not having been infected.

The point is, given the limitations of testing–which have to be taken as givens–such people can only later be seen as safely not infected. There is no way to be sure of that in real time, not even (as things currently stand) with testing. The pandemic puts us in the odd but undeniable situation of confronting rights violations engaged in with the best of intentions. Your best friend’s or significant other’s hug, kiss, handshake or conversation could kill you. Same with any passerby. Same with any student in a classroom. Same with any person behind the deli counter. Same with any dentist or dental patient. The goodness of their intentions–their lack of culpability–doesn’t mean that the harms they produce aren’t rights violations. The viral load they impose on those who end up harmed crosses the relevant sort of boundary: the victim’s immune system. When one person’s viral load overloads the immune system of another, you have a rights violation.

It doesn’t matter whether you can do all the relevant contact tracing; that’s an epistemic issue. The ontological, factual, and normative issue remains: no matter how complicated the etiology, the virus is transmitted from person to person. Each transmission is a separate rights violation. Each culpable transmission is a separate culpable rights violation. The epistemic and legal issues only come up once we accept the preceding facts, which I regard as pretty close to moral bedrock.

People like the dentist complain about the collectivist aspect of lockdowns: they lock everyone down regardless of “guilt” for transmitting the virus. But they ignore the fact that in the absence of a mechanism to trace individual culpability, supposed individualists demanding “freedom to operate” are ipso facto demanding the “freedom” to infect people with impunity. They’re treating other peoples’ immune systems as a commons into which COVID-19 can be dumped without liability.

But human beings cannot be treated that way. They can’t even legitimately be thought of that way. To do so is a colossal, monstrous immorality.* Yes, the dentist’s claims (1) and (2) are true. But his claim (3) is not sufficient to deal with the “disease-vector commons” objection I’ve just made. What angered me most was his insensitivity to this fact. He acted as though I had never lost money in my life, and had never suffered in my life, hence didn’t understand (1) and (2). But what I saw was someone who didn’t understand what it was like to be treated like human refuse. And as I saw it, he was exaggerating his competence at infection control to mask such an attitude.

A third weakness concerned (4). That the government was delaying without reason for delay that was discernible to him didn’t imply that it was delaying without actual reason. It was an open question whether he was looking at everything that needed discernment. And doubtful that he was.

I’ve belabored this micro-argument because, parochial as it is, I think it helps illustrate some larger points about how to discuss the lockdown/open-up controversy regarding COVID-19. Both sides in this dispute have legitimate points to make. But neither side is really acknowledging the best points the other side is making. And neither side is fully open to acknowledging the weaknesses in its own case. I still remain more of a lockdown than an open-up person. I fear the dangers of a second spike more than I fear the dangers of lockdown. And the more we open up, the greater the dangers of a second spike. But this is still a hybrid view, not a pure one–a matter of degree or emphasis, not of pure allegiance to a single policy. At this point, we clearly do have to open some things up, non-COVID medical procedures being at the top of the list.

The basic dialectical or discursive lesson here is that if you can’t ask real, truth-seeking questions of your interlocutor in the middle of a debate, you can’t track the truth in the debate. All you can do is lock down (so to speak) this position or that, and defend it to the hilt. That itself has a certain value (I’m not against it), if (and only if) you go back later to look at the results and see how they might have tracked the truth if arranged in a different way than they were in the actual debate. But don’t expect to track the truth in real time during a debate like that. It won’t happen. Each side is too busy defending its position to track anything but victory, taking victory-in-this-debate to be a proxy for truth.

The debate about open up and lock down is valuable and important, even at its angriest, but only when we step back from it, cool off, and assess the results. Having recently lost my job, I’ve had a chance to do a bit of that lately. I highly recommend it.

That came out wrong. I mean, I highly recommend assessing the results of the debate in a cool moment, not losing your job in order to do it.

*Not necessarily an  injustice, of course. Sorry to be so pedantic.

10 thoughts on “Coronavirus Diary (59): Arguing About Dentistry Under Lockdown

  1. Very interesting. I had to read this quickly because I have a busy day ahead of me; but one thing jumped out quickly–something I had sensed but not put into words until then.

    There is a contradiction in the anti-lockdown ideology: it includes an objection to state power. The lockdown is often characterized as an example of state-over reach. But as your comments say, much of the legitimate rationale for the lockdown is due to lack ability by the state to do things that would mitigate or abreviate the lockdown. The states are struggling with contact tracing and questions of liability; if these were quickly put in place back in January then there would be clarity regarding how to relax the lockdown. But those things are not clear yet (after 4 months) so the decision to relax is quite fraught.

    I’ll have to give this a better read later today.

    sean s.

    Liked by 1 person

  2. I just went to the dentist today — cleaning, x-ray, gum and general oral examination. Signed some stuff (indicating awareness of risk, but not explicitly releasing anyone from liability). Masks mandatory except while being examined. Dentist super-decked out in PPE (face shield, goggles, surgical mask, gloves, etc.); it was like a space alien was working on me. Had to gargle (and was encouraged to and did drink) an antiviral liquid. No breaks at all to clear saliva or blood — just a tube sucking it out for them to work. So more uncomfortable than normal. And no polishing because that procedure spits stuff all over the place. They indicated, at points, that they were following CDC guidance in doing things as they were doing them (my guess is that they would not have done quite as good a job safety-wise without the CDC guidance). I sanitized, took zinc and gargled with Listerine afterwards, after paying, getting in my car, taking off my mask, etc. For what any of that is worth! [ADDENDUM: They also took my temperature by putting a little device to my temple — 98.7 F — when I checked in. Also signed stuff to the effect that I am not sick and have not traveled recently.]

    Liked by 1 person

        • No, dude, my dentist is primo. I didn’t have dental insurance for years, and he worked with me. There is goodness in humanity. You won’t hear me saying stuff like that very often. Here’s my Yelp review. I was thinking about him as I wrote this post.

          He’s excellent. I’ve seen him since the mid-2000s, when I lived in the area. I now live an hour away, but have continued with him. Easy to get an appointment, easy to deal with the staff, and friendly dental assistants. He is himself the best dentist I’ve had. Early on, I didn’t have dental insurance, so I paid out of pocket, and his fees were completely reasonable. Eventually, I got Delta Dental, which made things yet easier. In maybe 15 years’ worth of visits, I don’t remember having a single unpleasant experience. Highly recommend.


  3. Well, I guess this is one way to solve the liability problem (ht: David Molnar):

    Really great to see my old university president first in line to abdicate moral responsibility on this issue. Translation: “There’s no danger to returning to on-campus instruction, but if you die, it’s not our fault.” It gives new meaning to the mantra, “Students First.” First into the hospital, I guess–then into the morgue.


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