Medical Practice or Service Business?

The theoretical starting point of this debate goes back to economist Kenneth Arrow, in a foundational health economics article published in 1963 in the American Economic Review 1963 · classic. Arrow shows that the medical care market differs structurally from ordinary commercial markets for one precise reason: uncertainty and information asymmetry between practitioner and patient.

Unlike a customer purchasing a standard good, the patient can neither precisely assess their own need, nor judge with certainty the quality of the service received — they must trust the professional who, for their part, decides both the diagnosis and the treatment they bill for.

The concept of "ethical fading"

Contemporary dental literature revisits Arrow's idea under a different name: that of a credence good. In an article published in 2025 in the British Dental Journal, Raj Rattan points out that the patient is structurally unable to assess for themselves whether the proposed treatment was genuinely necessary, or even whether its execution quality was optimal 2025.

He introduces the concept of "ethical fading": under commercial pressure (revenue targets, chair-time profitability), a practitioner may gradually lose sight of the ethical dimension of their decisions, without ever feeling they are deliberately acting wrongly — it is a gradual drift, not conscious dishonesty.

Holden's warning (2018)

Alexander Holden, in an article published in Medicine, Health Care and Philosophy, reaches a similar conclusion: an excessively "consumer-driven" practice risks reducing the fiduciary patient-practitioner relationship to a mere transaction, which runs counter to what patients actually expect from greater market choice 2018.

However, he does not argue for a total rejection of service logic — a patient is right to expect quality reception, transparency on fees, and responsiveness — but rather for vigilance regarding misleading commercial practices or price competition that might push treatment indications downward or upward.

A literature review published in 2020 in the British Dental Journal by Holden, Adam, and Thomson analyzed 47 studies on the question 2020. It identifies three recurring themes among practitioners interviewed worldwide:

A phenomenon observed in several countries is the proliferation of dental practices organized into chains or groups ("corporate dentistry"), managed according to logics close to large-scale retail or fast food. In a qualitative study conducted in Australia and published in 2021 in the British Dental Journal, Holden, Adam, and Thomson apply George Ritzer's sociological theory of "McDonaldization" to this phenomenon 2021: corporate practices tend to optimize four dimensions — efficiency, predictability, calculability (profitability metrics and targets), and control of the practitioner by the organization.

This debate is not merely academic: it is directly settled, in law, by the regulations governing practice in Algeria. Executive Decree No. 92-276 of 6 July 1992 on the medical code of ethics — which applies to physicians, dental surgeons, and pharmacists — states an explicit principle in its Article 20:

A very similar principle exists in the code of ethics for dental surgeons in France (Article R.4127-215 of the Public Health Code), which likewise prohibits practicing the profession "as a trade" — a sign that this requirement is not a local peculiarity but a shared foundation of the dental profession across several legal frameworks.

In concrete terms, this text does not mean that a practice should not be managed with financial rigor — nowhere does it prohibit that — but that no treatment decision should be motivated by a commercial objective, and that the profession may not resort to the same promotional methods as an ordinary commercial enterprise. This is the exact legal translation of the distinction drawn above: rigorous management on one side, non-commercial clinical decision-making on the other.