Article
Hindsight can be a great teacher. The purpose of this editorial is to outline briefly a 2500-year-old debate about the importance of providing, or at least searching for, accurate definitions, particularly about the nature of beauty, and how the debate is relevant to modern dentistry owing to its emphasis on dentofacial aesthetics, followed by a brief discussion regarding the potential relevance of this debate to modern dentistry, including some comments on the ethics of current practice.
A philosophical way of thinking involves questioning everything, including any values which may be ingrained in us and appear ‘normal’, primarily due to general societal acceptance. History demonstrates how many such deeply-held or traditional standards change over time as humanity progresses towards greater ethical values. The link with modern dentistry is discussed.
Many specialties of dentistry and medicine are concerned with external dentofacial and bodily appearance, which are often inextricably linked to internal psychosocial health and quality of life. Congenital, developmental, traumatic and pathological conditions may all affect a patient's dentofacial appearance. A key issue for clinicians is that an individual's appearance, and visible differences from the average, are all connected, potentially through evolutionary processes moulded by cultural forces and standards, to our understanding of beauty.1 It thereby follows that understanding the concept of beauty begins by attempting to define it.
Attempts to define beauty have been made from time immemorial by artists, philosophers and scientists, yet all remain debatable and fraught with difficulty. The Renaissance art theorist Leon Battista Alberti (1404–1472) defined beauty as: ‘The summation of the parts working together in such a way that nothing may be added, taken away or altered, but for the worse.’2 However, this could be a definition of perfection, and does not accurately define beauty. In 1896, the philosopher George Santayana (1863–1952) wrote: ‘Beauty as we feel it is something indescribable: what it is or what it means can never be said.’3 Santayana was describing the perception of beauty as a subjective feeling and thereby difficult to define, much in the same way that we know what it is like to feel love or fear, but the feelings can be difficult to articulate. Yet there is a plethora of evidence in the psychology literature that perceptions of beauty, particularly facial beauty, appear to be universal, even across cultures.4 TH Huxley (1825–1895) felt that recognition of beauty was intuitive,5 yet artists always maintain that the recognition of art, and thereby beauty, is an art itself, ie something to be learned.
An attempt to define facial beauty for clinical practice has been made:1 ‘The assemblage of graceful features that pleases the eye and mind of an observer.’ This definition contains the three variables required in a definition of facial beauty. Firstly, there are the ‘features’ – each human face comprises a number of features (units and subunits), with a wide array of sizes, shapes, colours and textures; their ‘assemblage’ describes how these various component parts fit together, like a mosaic, to create each face, and the relativity of parts that makes each face unique. And, finally, there is the ‘observer’ – does each observer see and sense the same beauty?
However, we are still left with a dilemma, in that none of these definitions answers the question, ‘What is beauty?’, a concept that should be foremost in the thoughts of any clinician.
The term ‘definition’ describes an exact statement or description of the meaning of something, which must be clearly expressible if it has been conceived well. Therefore, it would be fair to state that what cannot be adequately or clearly defined has not yet been fully understood. An attempt to find a definition of beauty may be found in one of Plato's dialogues, The Hippias Major (circa 390 BC) – a detailed exposition of the salient points required in the attempt to define beauty.6 Though written almost two- and–a–half millennia ago, the arguments do not appear antiquated.
As far as we know, Socrates (469–399 BC) left no writings, and is known predominantly through the dialogues of his student Plato. Plato (429–347 BC), born to nobility, initially contemplated a life in politics, but became distressed and disillusioned with corruption in Athenian democracy (Plato believed that without a broadly educated and enlightened populace, democracy would develop into mob rule), particularly after their execution of Socrates, and thereby turned to philosophy in order to seek for alternatives to the injustice of Athenian society. In the Academy, which Plato founded in Athens in order to stimulate critical thinking, one of the most significant areas of work was the task of providing accurate definitions.
According to Plato's dialogues, Socrates would debate the people of Athens regarding ethical issues and, through questioning and critical scrutiny, would demonstrate their weakness. This Socratic method, or elenchus (roughly translates as ‘cross-examination’), often begins with Socrates asking for a definition, which the responder provides, only to hit a metaphorical brick wall, with Socrates finding inconsistencies, inadequacies and contradictions in the definition, exposing the debater as ignorant and arrogant and eliciting deeper inquiry.
To the classical Greeks, there was an integral connection between a beautiful outward appearance and inner ethical goodness, ie to be beautiful was to be ethically good. However, Socrates felt that it was not enough to be outwardly beautiful but, to be truly beautiful, each individual had an obligation to develop a virtuous mind. Therefore, defining beauty became very important, and thereby became the subject of the Hippias Major. The dialectic is between Socrates, whose only claim to knowledge was that he was aware of this own lack of knowledge, and Hippias of Elis, a sophist, a school whose role was teaching rhetoric and persuasive public speaking to rich men with political ambition – which partly explains Plato's disdain for them. Hippias is presented as ignorant and self-satisfied, which provides the humorous effect of the dialogue. After some initial waxing and waning, Socrates begins by saying that he was talking recently to a hypercritical friend (whenever Socrates refers to his ‘friend’, he is referring to himself) about the question ‘what is beauty?’ and he feels that Hippias may be able to help. He coaxes Hippias into offering definitions of beauty, then responds by explaining how his ‘obnoxious friend’ would likely critique each potential definition provided by Hippias. Hippias' first effort is to say that ‘a beautiful maiden is beautiful’. Socrates, with his usual irony, commends Hippias, but suggests that the question is not what is beautiful, but what is it that makes a thing beautiful? Otherwise, one could say ‘a horse, or man-made objects such as a lyre or a vase, are beautiful.’6 Hippias tries again, saying that ‘gold makes a thing beautiful’, then again that ‘wealth and respect make a man beautiful’, to which Socrates jokingly responds that his friend would have beaten him with a stick had he provided such a ludicrous definition. Socrates then suggests some of his own definitions. Firstly, perhaps beauty is that which is appropriate, or that which is useful? For a clinician, the term ‘useful’ may be related to function, yet we know that ideal functioning of an anatomical part does not necessarily equate with beauty. Identifying that these cannot be enough, Socrates suggests perhaps that beauty is that which is pleasing through our senses of sight and hearing? Interestingly, this is very close to the modern definition of beauty in most standard dictionaries. However, Socrates provides his own rebuttal in that many things provide sensory pleasure but are not necessarily beautiful (eg eating), or may be even ‘repulsive to view’6 (Socrates, somewhat tongue in cheek, gives the example of carnal relations).
The conclusion of The Hippias Major dialogue appears to be that, when Socrates attempted to define beauty, he could find no common quality and eventually concluded simply that it was difficult to define. After two-and–a-half millennia, the concept of beauty continues to baffle and defy accurate definition. However, the Socratic dictum was that ‘the unexamined life is not worth living’,7 therefore our search should continue.
Discussion
Is there a connection between The Hippias Major dialogue and modern dentistry? There are two distinct yet potentially interrelated connections; the first is technical, and the second ethical.
Function vs aesthetics?
There is little doubt that modern society, fuelled by a materialistic media and avaricious corporations peddling products, is developing an ever-greater obsession with facial and bodily appearance.8 The number of patients with body image concerns and disorders is increasing dramatically.9,10 Unfortunately, rather than remain a distinct medical and surgical entity, beyond the reach of such ignoble touting, a small proportion of modern dentistry appears to have been taken up on this unhealthy tidal wave, promoting idealistic, sometimes detrimental and often impossible-to-achieve physical standards. As such, more of this aspect of modern dentistry progressively appears to be directed at quick fixes and purportedly ‘cosmetic’ or ‘aesthetic’ treatments,11-13 generally meaning alignment of front teeth, whilst ignoring function, health, the complexities of facial, smile and dentogingival aesthetic analysis and, in the long-term, quality of life.
High quality dentistry may easily follow the architectural maxim that ‘form follows function.’ The dental surgeon should be aware of a general guideline, that function should not be impaired at the expense of aesthetics, particularly short-term aesthetic improvements that are liable to fail, eg full mouth veneers/crowns in patients with poor periodontal health, or incorrectly planned and badly carried out orthodontics, usually involving alignment of anterior teeth without an understanding of other occlusal, functional and aesthetic parameters. Alignment isn't everything, but is broadly all that may be taught in a 1- or 2-day course, which some may view as a way of by-passing the long and arduous training necessary for proficiency. The dental clinician's motto should be: ‘Function and aesthetics in harmony’, as neither function without aesthetics, nor aesthetics without function, will lead to the ultimate goal of improvement in a patient's quality of life.
The ‘1- or 2-day course’ issue brings us onto another connection with modern dentistry, that of ethics.
Ethical considerations
The concept of the three stages of truth is often attributed to the philosopher Arthur Schopenhauer (1788–1860). It states roughly that every truth passes through three stages before it is accepted as an established fact:
These three stages are clearly evident on analysing the progress of rights, and thereby ethical standards, in Western Europe. A useful example is the development of women's rights. When Mary Wollstonecraft published her A Vindication of the Rights of Woman in 1792, arguing not so much for equal rights but predominantly for the right of women to receive an education and, as such, become self-reliant, her work and arguments were ridiculed almost across the board. One can almost still feel the reverberation of smirks as a Member of Parliament facetiously remarked, ‘Rights for women? What will they think of next, rights for animals?’14
By the late 19th and early 20th century, the growing suffragette movement was no longer asking for, but demanding, rights for women. They were now violently opposed, with orders from then Prime Minister, Herbert Asquith, for the police to use shockingly ruthless tactics to impede the suffragettes. Fast-forward to the modern day and women's rights and equality are accepted as self-evident by all but the most nasty misogynists. However, there are many other ethical challenges facing humanity, such as man-made climate change, the unnecessary yet almost universal abuse of animals in the intensive factory farming industry, unnecessary testing of cosmeceuticals or entertainment, and ensuing environmental disaster if we continue on our current trajectory. Yet, despite overwhelming evidence, the response of those in authority, and many people, is still in stages one (ridicule) or two (violent opposition) of the three stages of truth in relation to these issues. Equally, there are huge ethical challenges facing medicine, eg euthanasia, genetic manipulation, embryonic research, abortion, etc. The relevance of mentioning the above is to explain that there are many potentially ethically debatable issues that we accept as standard practice or take for granted, which future generations may deem unacceptable. One of the ethical problems facing modern dentistry is how to manage the albeit small number of clinicians interested not so much in patient care, but ‘get rich quick’ schemes, which brings us back to the ‘1- or 2-day course’ issue facing our profession. At its worst, quick fixes and money-making schemes are peddled with superlative marketing, often by self-styled ‘gurus’,12,13 backed by large corporations, usually to newly qualified dentists, generating and promoting the illusory belief that one may learn to place implants, undertake orthodontics, or give botulinum toxin or facial fillers by attending a 1- or 2-day course. It takes three years of full-time or equivalent part-time training to achieve the level of specialist for many dental specialties, yet most experienced clinicians will probably agree that is takes at least another five years to become really confident and proficient, and that is five years of life-long learning type hard graft. How can anyone propose to learn such information in a few days, and then to begin treating patients? What happens when things go wrong, as they inevitably will? Refer and let someone else deal with the problems? Problems may arise from incorrect use of botulinum toxin, or even worse, facial fillers due to misdiagnosis, eg the expressionless, immovable forehead, or the ever-more common ‘trout pout’, or more severe complications such as patients with fillers bursting in their faces, or going blind. Excessive tooth whitening is now commonplace, or full mouth veneers, with no significance placed on the patient's skin tone. A potential risk, particularly for younger clinicians, may be that they become misfocused and, in the meantime, perhaps risk neglecting basic dental skills.
Whilst speaking with clinicians at a variety of conferences, there appears to be a unanimous, albeit anecdotal consensus, that the number of complications from facial fillers, in some countries, is woefully under-reported. Patients often have little or no recourse to litigation and, as such, cases of quite severe complications are simply unreported. Whereas such complications on patients are intentionally ignored, all the while animals are being subjected to horrifying medical experiments to test the safety of the same materials. Perhaps burying our heads in the sand is how we numb our collective moral responsibility to such atrocity.
From a utilitarian perspective, we know that actions have consequences, yet if our actions please us, even when the consequences for others are negative, we seem to be adept at ignoring the consequences, pretending that they don't exist, being apathetic, becoming aggressively defensive, or making ridiculous excuses, eg if I don't do it somebody else will.
With the anticipation of disarming some of the criticisms which the preceding views may evoke, it is important to point out that the vast majority of dentists in the UK work to the highest ethical standards and, although there is no doubt that, with appropriate training, dental surgeons have a vast array of skills to offer their patients, there is also a potential risk that poorly trained dentists may embark on undertaking treatments for which they are not competent, whose risks they don't fully comprehend, and whose complications they cannot deal with. History demonstrates that many accepted practices are open to serious ethical objections when viewed with hindsight. How will the future dental profession view current practice?
Conclusion
The Socratic dictum remains that ‘the unexamined life is not worth living’. We may not yet have found the perfect definition of beauty, but the search for beauty in its many forms, including ethics, should continue. Ethics is the essence of our profession. We can all do better.