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Ethical Dilemmas Reported by Fourth-Year Dental Students

Key words: ethics education, dental education, clinical clerkship, dental ethics, bioethics

Submitted for publication 04/29/05; accepted 06/21/05

	Abstract

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 
Ethics education in dentistry is a requirement for accreditation. Despite universal adoption of ethics courses, there is ongoing discussion about the appropriate content of these courses and about methods to engage students. Faculty who teach ethics must select a limited set of topics from the broad fields of professional ethics, bioethics, and the humanities. The purpose of this article is to describe the ethical issues reported by fourth-year dental students during community-based extramural clinical experiences. Senior dental students (n=123) wrote essays describing an ethical issue they encountered during one of two extramural rotations. Ethical issues were categorized and coded by consensus between two faculty authors. Students most often reported perceived dilemmas related to patients’ limited resources (25 percent), conflict between professionals (19 percent), clinic policy or procedures (15 percent), and decision making by patients’ surrogates (13 percent). One student (<1 percent) reported encountering no ethical issues. Students’ perceptions of ethical issues in clinical practice offer faculty a foundation for designing a dental ethics curriculum that is practical and immediately relevant to the experience of a dental student. Students’ reports may also yield a method for systematic assessment of students’ abilities to apply classroom ethics instruction to clinical practice.

Underlying the debate about the efficacy of ethics education is some ambiguity about the specific topics that should be included. While some concepts, such as informed consent, are clear in the accreditation standards, others such as cheating are the subject of discussion among educators.^2–5 In general, the selection of topics covered in ethics courses is at the discretion of the individual instructor. The scope of ethics in health-related disciplines is enormous and the time allocated to ethics instruction is limited, so instructors must prioritize among possible topics. Individual preferences and interpretations of what an ethics course should cover lead to wide variation in course content across programs. This variation is highlighted in a survey of the content of ethics courses in eighty-seven of 121 medical schools in the United States.⁶ This study yielded thirty-nine ethics content areas with little consistency across programs. Informed consent was the most common ethical issue taught across 84 percent of the programs who responded. Only six of the remaining topics were taught by at least half of the medical schools.

While the dental education literature includes discussion of approaches to teaching ethics,^2–5,7 there has been relatively little discussion about how instructors should prioritize course content within the confines of an already crowded dental curriculum. A number of text and case books illustrate ethical issues that arise or could arise within the practice of dentistry.^8–10 Despite the availability of this literature, none of these sources provide data to support the extent to which ethical issues actually arise in the practice of dentistry.

An additional challenge to ethics instructors in any health-related discipline is student acceptance of the value of ethics courses. Students may resist instruction in ethics, questioning whether ethics or moral behavior can or should be "taught" at this stage of professional or personal development.^2,4 In addition, ethics educators struggle with the perception on the part of students and administrators that ethics is dry and boring.^2,4 The medical education literature suggests that students are more engaged in ethics education when the issues are directly relevant to them.^11–13 In addition to student-related issues, medical ethics education is increasingly focusing on everyday ethical dilemmas, "rather than on sensational cases of the type that occur only rarely."¹⁴ In addition to increasing student engagement, Musick suggests that student-generated ethical issues could tangibly increase students’ abilities to notice ethical issues in clinical practice.¹⁵ Moral and ethical issues perceived by medical students and residents have been reported.¹² In dentistry, reflection essays, reports of critical incidents and significant events, and debriefing sessions yield examples of ethical and moral issues from the students’ perspective.^16–18 However, to our knowledge, there has not been systematic collection of students’ reports of the ethical dilemmas they observe while in dental school.

The purpose of this article is to describe the ethical issues that dental students perceive while engaged in extramural clinical practice. These data are expected to aid faculty and curriculum committees in developing ethics curricula that are immediately relevant to dental students.

	Methods

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 
Dental students at the University of Iowa are assigned to two extramural placements, each of approximately five weeks duration, in their fourth year. Upon completion of the two back-to-back rotations, students spend one full day in a group seminar that allows the students to share their experiences in a quasi-structured format. In preparation for this seminar, all students write a paper describing and analyzing an ethical issue they encountered during their rotations (assignment is shown in Appendix A). These papers are required to complete the extramural experience, but are not assigned a grade. The seminar provides an opportunity for the students to discuss their perceived ethical dilemmas, including how they might handle the situation should they encounter a similar circumstance in the future.

Written assignments were obtained from 123 fourth-year dental students. This sample represents papers submitted by all students from six cohorts of students who completed extramural rotations in 2002–03. To ensure confidentiality, analyses of the blinded essays were conducted after the students graduated from the program. This systematic study of completed student assignments was reviewed and classified as exempt by the Human Subjects Office at the University of Iowa.

Fifty randomly selected papers were reviewed in order to develop preliminary categories for the ethical issues described by the students. Twenty different papers were then selected for a trial consensus coding. The coding system was revised to include sixteen primary ethical issues; these categories are listed in Table 1 with an example of an issue that falls within each category. Where given, the patient population most affected by the perceived dilemma was identified according to age brackets as follows: pediatric (<18 years), adult (18 to 64 years), or geriatric (>65 years).

	Results

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 
One hundred and twenty-three student essays were coded and yielded 172 primary ethical issues. One student reported never encountering an ethical issue during two extramural rotations. Most of the students’ papers were reports of a single case that included clinical facts followed by a discussion and analysis of the problem. Some students elected to write about a general concern: for example, being unable to provide optimal care for multiple patients who could not pay for services.

The most often identified ethical issue was patients’ lack of resources, reported by thirty-one (25 percent) students. Disagreements between professionals on the care team were reported by twenty-three students (19 percent). Clinic policies or specific procedures that the students perceived as inconsistent with the standard of care were reported by nineteen students (15 percent). Issues related to surrogate decision makers were reported by sixteen students (13 percent). All other primary ethical issues were reported by less than 10 percent of the students: patients’ capacity for decision-making (9.8 percent), parent or patient demand for treatment the students perceived as inappropriate (8.9 percent), parent or patient refusal of the proposed treatment plan (8.9 percent), and neglect of dental care by a parent or caregiver (8.1 percent); students’ concern with their own competence, truth-telling or disclosure, and issues of dealing with difficult patients were each reported by six students (4.9 percent). The least often reported issues included: observed errors or mistakes (three; 2.4 percent), treating patients without appropriate consent (three; 2.4 percent), cultural issues of preference or communication barriers (two;1.6 percent), breaking bad news to a patient (one; 0.8 percent), and a breach of confidentiality (one; 0.8 percent). Eleven students identified "other" ethical issues not included in the coding scheme, such as patients altering narcotic prescriptions. Additional specific issues raised in this category are not reported here because the unique circumstances might allow the student, patient, and/or facility to be identified. The frequencies with which students identified primary ethical issues are summarized in Table 2.

	Discussion

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 
Dental students perceive a variety of ethical issues during their clinical training. Of 123 students given an assignment to write about an ethical issue encountered during ten weeks of extramural clinical experience, only one student reported never observing or experiencing any ethical issues.

Students’ essays necessarily reflect the students’ perceptions of what constitutes an "ethical" dilemma. Some might argue that some of the issues identified by students, such as conflicts between students and supervisors are not necessarily "ethical" issues, but rather reflect professional, social, or hierarchical issues inherent in the clinical education process. In some cases, this argument is well founded. Some reported conflicts between team members reflected relatively minor issues such as staff disagreements over scheduling or personality conflicts. However, within the subtext of hierarchical disagreements, many students raised true moral dilemmas—for example, a disagreement between student and supervisor about whether to disclose an error to a patient. Similarly, some might construe social inequities as a function of oral health policy as opposed to personal or professional ethics; however, it is clear from these data and findings previously reported by Mofidi et al.¹⁶ that students perceive these disparities as ethical issues. That so many students perceive financial limitations to accessing optimal dental care as an ethical dilemma suggests that students struggle with a sense of obligation to treat patients fairly and equally and are troubled when they are unable to do so. Whether or not one perceives these dilemmas as issues of ethics, the frequency with which students perceive these issues as ethical issues suggests that frank discussion about access to dental care and the occurrence of interprofessional conflict in clinical practice should be included somewhere in the dental curriculum.

Interpretation of these data is restricted by a number of limitations. The assignment was completed by students at only one dental school. At the University of Iowa, the core ethics curriculum is taught in the first and third years of the program. In the first year, ethics instruction begins with a lecture during orientation week. A series of three lectures is coupled with case-based discussions in groups of twenty-five students with the course director. In the third year, one overview lecture is followed by four small group discussions with ten to twelve students and two faculty dentist facilitators. It is possible that the students’ exposure to ethics through the local curriculum influenced their perceptions of what an ethical issue is and, therefore, what they observed or chose to report. While this possibility should be explored through the inclusion of other schools with different ethics curricula, it should also be noted that these students had different ethics course directors, different discussion leaders, and different content emphases in the first and third years of their program.

The frequency with which ethical issues were reported by students may not be related to the frequency with which these issues occur in practice, nor should these data suggest that the curriculum should be limited to the topics most often reported by students. The students did not identify why they selected the issue they wrote about, and they were not directed to write about ethical issues according to frequency or how troubling the issue was. In debriefing sessions on their return to campus, the students stated that they selected issues for a variety of reasons. The most common reasons for selecting the case or issue they reported were highest frequency, most troubling, most memorable, or an issue that was unexpected. Some issues traditionally included in ethics curricula, such as observed breaches of confidentiality, mistakes, and breaking bad news, were rarely addressed in the students’ written reports. However, the debriefing sessions reveal that while few students wrote about these issues, they readily acknowledge that they observed occurrences of these ethical dilemmas. Breach of confidentiality serves as a good example of an issue that was raised by only one student in the written assignment, but during debriefing sessions more than half of the students acknowledge that they observed breaches of confidentiality. Therefore, "low incidence" issues reflected in these data should not be used to eliminate core topics, such as confidentiality, from the curriculum. Discussions with students following their clinical experiences can serve as a method for instructors to enrich their understanding of the student experience and help uncover examples of ethical issues that future students should expect to encounter.

Despite the limitations of this study, the ethical issues reported across students provide a reasonable framework for identifying the kinds of issues future students are likely to encounter and are likely to identify as ethical issues. Ethical issues as perceived by clinical students can be used to develop and implement an ethics curriculum that is relevant to preclinical students. These data also suggest that ethics curricula should include a variety of examples from pediatrics and geriatrics as well as adult clinical settings. Understanding the issues that are most likely to arise within particular populations or disorder areas yields good opportunities to integrate ethical issues into the broader curriculum. Ethics "infusion" through the program can reinforce freestanding lectures and case discussions or may replace free-standing coursework in ethics if carefully woven through the curriculum.

We have used the themes reported by fourth-year students to develop our preclinical and clinical core ethics curricula. The issues raised by upper class students have face validity for beginning students, thus lending relevance and credibility to ethics education. The issues are woven into cases that are carefully crafted to eliminate identifying information for patient, clinical site, student, and supervising dentist. Knowing the outcome of the case (or a similar case) allows the instructor to inform the students about "what really happened" after a discussion and analysis. Students report that learning how the case was resolved in practice is a valuable addition to case-based discussions.

As an ongoing assignment, students’ written observations allow faculty to track whether students’ perceptions of ethical dilemmas reflect retention of previous learning and whether students’ perceptions change over time, in new clinical settings, or in conjunction with revised education programs. Students’ ability to identify ethical issues and apply a reasoned decision-making approach to a real dilemma is an ideal goal of formal ethics instruction.² A reflective writing assignment that captures students’ ability to identify ethical dilemmas and apply ethical reasoning to novel situations should allow instructors to assess whether students meet this goal by the end of dental school.

Future iterations of writing assignments should include specific questions that require the student to label the ethical issue, identify the patient population and practice site, and describe why they elected to write about this case or issue (see example in Appendix B). Interviews, surveys, and focus groups would also contribute to our understanding the experience of being a dental student. These techniques should also be applied to practicing dentists in various settings to identify the frequency with which particular ethical issues occur in clinical dentistry. Such data will contribute to the discussion about how to standardize ethics education in dentistry and allow individual instructors to construct ethics coursework that is relevant to the day-to-day practice of dentistry.

	Appendix A. Assignment Used in the Current Study

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 

1. What are the technical/dental facts in this case?
   
2. What are the human, interpersonal facts in this case?
   
3. Identify the possible choices that the principal ethical actor might make in this situation and under what conditions. (List all possible options.)
   
4. Indicate the ethical grounds (moral principles and norms such as veracity, beneficence, nonmaleficence, confidentiality, autonomy, etc.) that would support each choice of action and also those moral norms that would be violated by each possible choice of action.
   
5. Which choice identified in #3 above would you recommend, and how would you support and defend it?
   

	Appendix B. Revised Assignment

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 
Case Description

1. What are the clinical facts in this case? (e.g., age, diagnosis, prognosis, dental goals, relevant history)
   
2. What are the contextual facts in this case? (e.g., social issues, behavioral issues, financial concerns, employment, distance, clinician’s goals, policies)
   
3. What are the patient’s (or family’s or both) preferences and goals in this case?
   
4. Identify and give a brief (one to two sentences) description of the primary ethical issue or problem in this case.
   
5. Give a brief summary of what actually happened in this case.
   
6. Briefly describe (in one sentence) why you selected this particular issue or case to write about.
   

Case Analysis
If a case like the one you described were to happen again in your practice or as you continue your training . . .

1. List at least three possible options you might have.
   
2. Select the best course of action from among your options in part a.
   
3. Justify your decision by explaining your reasoning. Use moral or ethical arguments to support your position, e.g., principles of patient autonomy, beneficence, nonmaleficence, or justice; the ADA code of ethics; other ethical theories. Include any moral or ethical principles or standards that would be violated by your choice.
   

	Footnotes

 
Dr. Sharp is Assistant Professor, Department of Speech Pathology and Audiology, Western Michigan University and Assistant Professor (Clinical), Department of Preventive and Community Dentistry, University of Iowa; Dr. Kuthy is Professor and Chair, Department of Preventive and Community Dentistry, University of Iowa; and Dr. Heller was Assistant Professor, Department of Preventive and Community Dentistry, University of Iowa until his death. Direct correspondence and requests for reprints to Dr. Helen M. Sharp, 1903 W. Michigan Ave., Western Michigan University, Kalamazoo, MI 49008; 269-387-8024 phone; 269-387-8044 fax; helen.sharp{at}wmich.edu.

	REFERENCES

Top Abstract Methods Results Discussion Appendix a. assignment used... Appendix b. revised assignment References

 

1. Commission on Dental Accreditation. Self-study guide for dental education programs. Standard 2 educational program: standards 20–22. Chicago: American Dental Association, 2000:32.
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8. Ozar DT, Sokol DJ. Dental ethics at chairside: professional principles and practical applications. 2^nd ed. Washington, DC: Georgetown University Press, 2002.
9. Rule JT, Veatch RM. Ethical questions in dentistry. Chicago: Quintessence Books, 1993.
10. Weinstein BD. Dental ethics. Philadelphia: Lea & Febiger, 1993.
11. Bisonette R, O’Shea RM, Horwitz M, Route CF. A data-generated basis for medical ethics education: categorizing issues experienced by students during clinical training. Acad Med 1995;70:1035–7.[Medline]
12. Christakis DA, Feudtner C. Ethics in a short white coat: the ethical dilemmas that medical students confront. Acad Med 1993;68:249–54.[Medline]
13. St. Onge J. Medical education must make room for student-specific ethical dilemmas. Can Med Assoc J 1997; 156:1175–7.[Abstract]
14. Culver CM, et al. Basic curricular goals in medical ethics. New Engl J Med 1985;312:253–6.[Medline]
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16. Mofidi M, Strauss R, Pitner LL, Sandler ES. Dental students’ reflections on their community-based experiences: the use of critical incidents. J Dent Educ 2003;67:515–23.[Abstract]
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