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Ethics Education in Dental School: Continuing the Conversation

Dear Dr. Alvares:

In "Why Our Ethics Curricula Don’t Work" in the April 2004 Journal of Dental Education ( J Dent Educ 2004;68:412–25), Dr. Charles N. Bertolami raises thoughtful questions about the efficacy of current teaching methods in ethics curricula for dental students. Underlying his sometimes-blistering critique, Dr. Bertolami retains a fundamental belief that dental schools should teach ethics, but could do better. We agree with his premise and with many of the issues he raises. Dr. Bertolami identifies three primary weaknesses of ethics education: "more education is not the answer to everything, ethics is boring, and course content is qualitatively inadequate" to achieve true behavior change (p. 416). We have not solved all of these problems at the University of Iowa; however, a number of our program initiatives speak to Dr. Bertolami’s concerns and may prove useful to other programs that have identified similar problems.

Dr. Bertolami uses cheating as an example of the general failing of ethics education programs to alter the fundamental moral fabric of dental students. We submit that students who cheat are well aware that cheating is wrong, but they choose to cheat anyway. We do not dispute the importance of encouraging morally appropriate conduct within any profession, and recent news reports in business, medicine, and the military emphasize this need. In full concurrence with Dr. Bertolami’s first weakness of ethics education, it seems doubtful that additional formal instruction regarding the immorality of cheating would alter the behavior of these few students. In fact, it seems likely that such instruction would offend or bore the majority of students. If there is a general failing in our educational programs, it appears to be a systemic avoidance of confronting unethical behavior within these programs. In a study of medical students’ reports of their own cheating, a student reported that "one student was repeatedly seen cheating independently by several people and reported to the administrators. Nothing was ever done!"¹ Rather than adding more instruction about the rules of conduct, programs should consider the messages students receive from administrative responses to moral and ethical problems.

The second major weakness that Dr. Bertolami discusses—"ethics is boring"— is inconsistent with our experience of teaching ethics across the dental curriculum at Iowa. He cautions against ethics courses taught by "ethicists" as potentially "grindingly dull" and also highlights the dangers of dentists turning to "moralizing" and "preachy little sermonettes" when teaching ethics. We address these potential pitfalls through collaborative teaching between faculty with training in ethics and faculty dentists. Courses are coordinated by a clinical ethicist who works closely with dentists and senior students to develop cases and course materials. Discussion groups in the third year are facilitated by faculty dentists who participate in three hours of training with the course coordinator. The meetings allow dentists to shape the course content and review the cases for accuracy and timeliness.

This course approach yields several desirable outcomes. The students are engaged in lively classroom discussions, and the students’ course evaluations reflect positive responses to issues and cases that they view as realistic and relevant to their current and future practice in dentistry. Perhaps most important, the faculty involvement broadens the ethics curriculum beyond the limited structured coursework. Students continue to identify the faculty facilitators as "point-persons" in various clinical sites within the college, which provides an ongoing source of ethics consultation and alerts the dental faculty to new issues that are then fed back to the coordinator of the courses. The buy-in from the faculty increases the relevance of the themes for the students and promotes responsibility for ethics education throughout the college and across the curriculum.

We wholeheartedly agree that dental curricula cannot rely on a few independent lectures and discussions about ethics as the sole source of ethics instruction for students. In medicine, it is well documented that students’ ethical and moral decision-making erodes as they progress through their training.² This erosion is primarily ascribed to the "hidden curriculum" or the learning that occurs from negative models of clinical and professional behavior that students observe during their training. While formal courses in ethics and Dr. Bertolami’s proposed pre-curriculum are a strong starting point, it is critical that this learning is reinforced throughout students’ classroom and clinical experiences. We believe observation of "good ethics technique" is the single most powerful learning tool programs can employ.

Ethics education is an enormous responsibility and challenge for all professional training programs. Dr. Bertolami has started an important conversation that we hope will lead to further debate about how to teach ethics effectively. We look forward to further discussion based on the continued belief that ethics education is a worthwhile endeavor. Further examination of the value and outcome of ethics education will help faculty draw together ethical theory and the practice of dentistry and make ethics education more effective and anything but boring for our students.

Footnotes

Dr. Sharp is Clinical Assistant Professor and Dr. Stefanac is Associate Dean for Patien Care, University of Iowa College of Dentistry. Address correspondence to Dr. Helen Sharp, Department of Preventive and Community Dentistry, College of Dentistry, N329 DSB, University of Iowa, Iowa City, IA 52242; 319-335-8700 phone; 319-335-8851 fax; Helen-sharp{at}uiowa.edu.

REFERENCES

1. Dans PE. Self-reported cheating by students at one medical school. Acad Med 1996;71:S70–2.[Medline]
2. Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? students’ perceptions of their ethical environment and personal development. Acad Med 1994;69:670–9.[Medline]

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