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Critical Issues in Dental Education |
Key words: ethics, dental education, curricula, integrity, professionalism
Submitted for publication 10/06/04; accepted 11/29/04
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Abstract |
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 Top Abstract Dental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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The essays compiled into this article offer some alternative views of ethics and ethics instruction from the perspectives of students, administrators, and faculty at one dental school. Three dental students discuss student attitudes and the pressures on students that may facilitate unethical behavior. They also discuss whether the ethics curriculum at our school affects student behavior and how ethics should be taught. The essay by the dean of students discusses faculty and student attitudes that affect ethical behavior and the difficulty students have transitioning from undergraduate to professional students. The final two essays are by faculty members who teach ethics. The first examines Bertolami’s proposals for teaching ethics, especially addressing his ideas concerning the importance of "enlightened self-interest." The last faculty essay makes suggestions about the best method of achieving ethical student behavior in a dental school and compares these to Bertolami’s proposals.
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Dental Student #1, Michael Albazzaz |
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TopAbstractDental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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Even if students enter dental school with good moral character, they may not be receptive to instructors who attempt to challenge their ethical reasoning. It is easy to attribute this to simple close-mindedness, but there may be more complex issues at work. For example, I have witnessed a concept I will refer to as "dental student apathy," which I can describe as a state of mind in which a student accepts lower standards of performance or unethical behavior simply because he or she is a student. This act of rationalizing unethical behavior may extend into the classroom or the clinic. It may spring from students’ lack of desire to hold themselves to the higher standard that professional students purport to, or the attitude may provide them with a rationalization for accomplishing a goal such as faster patient completion. Unfortunately, this leaves the school to struggle with the dilemma of whether it graduates competent caregivers who practice ethically.
So, what are dental schools to do in order to encourage ethical behavior? First, I believe that schools must define what triggers unethical behavior. In my view, much of the unethical behavior that occurs in dental school results from base emotions such as fear, greed, and envy. The desire to specialize after graduation, for example, drives many students to perform acts that I like to think they would not do outside of class, all in an attempt to achieve a ranking higher than the student sitting next to them.
Is it possible to teach ethical behavior? The upbringing of the student certainly matters, but in my view, a student’s response to an ethically challenging situation rests in part from the student’s initial indoctrination into dental school and the pressures the school places on the student. However, I do believe that it is possible to encourage students to be introspective. If students can be true to themselves and look beyond the dental school microcosm, they may be able to witness the larger concepts that are at stake when they adopt the role of caregiver.
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Dental Student #2, Siddhi Doshi |
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TopAbstractDental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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However, to know what is ethical is different from behaving ethically. In my experience, I’ve seen students who are unwilling to treat HIV positive patients, fearing the possibility of a needle stick. I have met dentists who believe that obtaining insurance money by charging insurance companies for additional procedures not performed on the patient and therefore not charging the patient is in the best interest of the patient. This is wrong, but do they understand the consequence of behaving unethically?
Ethics should be taught in two parts. First, students must learn the code of ethics. The second part of an ethics class should focus on introspection, so that students understand the consequences of their actions. Most people understand they are doing something wrong, but they don’t understand the consequences of behaving unethically.
Guiding students to think ethically on a regular basis tends to be more difficult than teaching a code of ethics. Different individuals choose different ways to deal with ethical dilemmas because they weigh the pros and cons differently. For instance, if a public aid patient comes in with tooth pain, I know that I should give the patient the option of a root canal or extraction. However, if the patient is dead set on keeping the tooth, but cannot afford the root canal, do I let them leave the clinic in pain and wait for the tooth to get to a point where it is hopeless, or do I push for the extraction because I believe relieving the patient of pain is my job? While some dentists value patient autonomy, other dentists would rank comfort higher on their list of values. We encounter ethical dilemmas regularly. Small group discussions allow us to debate how we would handle different situations. There is not just one correct way. By listening to different opinions of students, one may find a "more proper" solution to an ethical dilemma.
Cheating is a good example of how fear drives us to do the right thing. Living in the stressful, competitive environment of dental school, all of us have considered cheating. However, most do not, because they fear the consequences such as expulsion and disgrace. Peers from my school and others agree that when a student was caught for cheating and disciplined by only a "slap on the wrist," more and more individuals began cheating. There was nothing to fear. By teaching the consequences of unethical actions, you are encouraging students to avoid unethical behavior. Ethical teaching could be adapted to the various stages we go through in dental school by focusing on cheating in the earlier years and moving on to patient care issues in the later years. While I don’t believe fear is the only factor that prevents one from cheating, I do believe that most students feel it is the major driving factor that prevents cheating in dental school.
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Dental Student #3, Victoria Rinando |
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TopAbstractDental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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Group discussions were essential during this kind of learning. I found myself reaching new conclusions about how I would react in an ethical situation after following the guided steps with other students. I also appreciated the group discussions. I was able to see what kind of conclusions my peers came to, which in some cases were very different than my own. After discussion, I was able to witness some students realizing that their previously conceived notions about certain ethical dilemmas would in fact change after mentally walking through this process. After group discussions for the course, I also witnessed these conversations continuing out of class and onto the clinic floor. I began seeing students raising other questions and having discussions with friends about ethical choices. I believe that incorporating ethics into the dental curriculum stimulates conversation and thought about subjects that generally most students have curiosity and feelings about, but lack a proper forum for discussion.
In dental school there is fierce competition to specialize. The standards are very high to gain entry to any dental specialty program. If you are able to secure a spot, your lifelong average income has excellent potential to be significantly higher than that of general practitioners. Therefore, it is possible that performance while in dental school will have an effect on your later income, security, work schedule, and so on. A small edge that one student may have over another can affect the rest of their lives. Knowing this, students view dental school as not only an educational experience, but as a competition to achieve added benefits.
A dental school that attempts to graduate highly moral and ethical professionals should also value the importance of encouragement and reward. Rewards should be given to students who, for example, have perfect attendance, make a vast improvement in their grade point averages, volunteer in community settings, and so on. These rewards do not have to be financial, but simply kind gestures of congratulations for hard work well done. All too often in dental school these small but nevertheless important achievements are overlooked. Instead, dental schools spend more time rewarding students whose achievements are more recognizable, for example, the highest GPA, highest clinical production, and so on, but not necessarily achieved by holding high ethical and moral standards.
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Associate Dean for Student and Diversity Affairs, Dr. Darryl D. Pendleton |
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TopAbstractDental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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That’s because some faculty and staff create an obstacle course loaded with put-downs and insults, which ultimately defeats the lessons taught in ethics curricula and simply perpetuates the cycle. Such obstacle courses have little to do with training dental students and lots to do with making sure students recognize that they are subordinates. Students recognize these intentions and learn to navigate the curriculum through gamesmanship. For them, gamesmanship is perceived as a normal milieu for dental school, which furthers the disconnection between academic and professional behavior. Thus, instead of matriculation, students view graduation as the dividing line between the educational and professional phases of their lives.
Faculty and staff should emphasize ethical behavior by both example and coursework throughout the dental school environment, so that students can make those connections. Dental students, as those in other occupations, will often just repeat what they see around them. If they witness favoritism, prejudicial behavior, or power games, it only dilutes their opinion of the value of morality in dental education and diminishes the meaning of ethics curricula.
Dental schools and organized dentistry can offer some solutions that aren’t structured around courses. First, they should view dental students as colleagues-in-training; after all, students are already treating patients and diagnosing and treating dental diseases. In four years, they will share the privileges and stature of others in the dental profession. Second, in order for students to succeed, both ethically and academically, they need to be exposed to the world of dentistry outside the four walls of a classroom. This will encourage an earlier adoption of the professional role and provide students with opportunities to develop their identity as ethical professionals. If dental education presents clear expectations of students and treats them with the dignity and respect deserving of colleagues, the outcomes will be much more predictable.
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Faculty Member and Ethics Instructor, Dr. Anne Koerber |
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TopAbstractDental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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I agree that lectures are not effective formats for changing student behavior, but they are effective formats for transmitting knowledge of codes as one student mentions in her essay in this series. Contrary to his argument, students do not come into dental school already understanding what is ethical as it applies to the practice of dentistry. Whether you are ethically obliged to treat HIV patients, whether you are obliged to present alternative treatment plans to a patient, whether you can distort insurance forms on behalf of a patient, whether you can "give up" on an unpleasant patient with whom you have started treatment are not issues that we learned in kindergarten, or even in college. These ethical concepts must be transmitted to students.
The outcomes that are reasonable to expect from ethics lectures are an increase in knowledge of ethical principles, along with an increased awareness of and ability to recognize ethical issues when they arise. The outcomes that one can expect from a small group discussion of ethical dilemmas are the ability to recognize ethical issues when they arise and improved skill in applying ethical decision making to a problem. Small group discussions may also lead to some internalization of the norms of the profession by students. When the groups are lead by clinical instructors, they provide a role model of ethical behavior, and through discussion of their clinical experience, they have what appears to me to be a profound impact on student behavior. However, even small group discussions don’t guarantee that a student will want to behave ethically, or will choose to do so.
Bertolami proposes an alternative that he feels will be more effective than encouraging students to behave ethically: namely, using small group discussions to guide them to see that ethical behavior is in their self-interest. He suggests putting ethics education into a precurriculum or, if offering it as part of dental school, making it elective. He appears to feel that the precurriculum is necessary to help students withstand the pressures of their peers and of dental school. He recommends opportunities for guided introspection focused on helping the student understand his or her true long-term self-interest. I agree that opportunities for guided introspection are important to encourage students to internalize ethical norms. However, I am puzzled by his recommendations that ethics teaching be part of a precurriculum or be an elective, which would seem to marginalize its importance and not accomplish his aim of changing student behavior.
His most controversial proposition to encourage change in student behavior is to guide the student to "enlightened" self-interest. He argues that if a student is helped through introspection to understand his or her true long-term interests, ethical behavior is most likely to follow. His thinking appears to be based on two assumptions. First, he believes that students will see that their long-term happiness lies with being true to themselves, which usually means behaving ethically. Second, he believes that if students are encouraged to think things through, they will realize that the risks and costs of unethical behavior are not worth it, especially since as dentists they will be doing well enough that they can afford to behave ethically. He then suggests that the most important ethical lesson a student can learn is how to recognize when his or her own interests conflict with the patient’s and avoid those situations.
By bringing self-interest into the issue of ethical behavior, Bertolami has taken a radical step away from conventional ethics pedagogy, which is based on making ethical decisions regardless of self-interest.18 In fact, ethicists argue that teaching self-interest is exactly contrary to what ethics pedagogy is about and certainly antithetical to how it is taught in most medical schools.18–20 Furthermore, so doing would open the possibility that students (or dentists) could justify their choice of behavior with arguments of self-interest.
This does not deny that ethical behavior can be a material benefit to a dentist. An example is good relationships with patients. The ethical dentist establishes a relationship with a patient that allows the patient to ask questions, understand treatment options, and make appropriate treatment decisions. Establishing this kind of relationship is also good for business, since it tends to keep patients and attract referrals. It certainly would be useful to point out to students when self-interest coincides with ethical behavior and when they conflict.
Self-interest and ethics are also congruent insofar as punishment is likely to result from discovery of unethical behavior. Clearly, if the risk of engaging in unethical behavior is to be punished, the long-term self-interest is to avoid that behavior. Our student essays point out the need to have consequences to unethical behavior. Unfortunately for Bertolami’s argument, this rationale doesn’t work if the risk of either being caught or being punished is low. Students point out that the reaction to lack of punishment is an increase in cheating.21–23 Some dentists probably engage in unethical behaviors that are unlikely to attract attention—such as describing a sealant as a Class 1 composite in order to obtain better reimbursement, or even "opening the fissure" to turn the sealant into a Class 1 composite. It is also fairly safe to assume that those who knowingly engage in unethical behavior do not expect to be caught. Contrary to Bertolami’s thesis, if the risk of being caught is perceived as low and the immediate gain is high, self-interest would lead a person to choose the unethical behavior, unless there was some other incentive to behave ethically.
It is conceivable that some students and dentists would be motivated to behave ethically by understanding the long-term consequences of the behavior on society and the profession of dentistry. For example, the perception that dentists are deceitful on insurance claims is one reason given by insurance companies and Medicaid to justify not covering dental procedures that aren’t materially demonstrable, such as patient education services or nonpharmacologic anxiety-control procedures. If dentists and dental students understood that link well enough, dentists and the profession as a whole might be motivated to control themselves better, in order to gain the trust of insurance companies so that these less tangible services could be covered.
Another possibility is that dental students would, through introspection, realize that their sense of themselves as good people and honorable dentists is dependent on ethical behavior and that behaving unethically will hurt them in the long run by reducing their self-esteem. I do see that teaching ethics as Bertolami does, to a group of already-motivated students who choose to take an elective in ethics, would help that special group of students to be strengthened to withstand pressures to behave unethically. However, it does nothing for the students who do not take the elective. It is not clear that most students would make this connection, since students, like the rest of us, are masters of rationalization and are usually readily able to avoid thinking of themselves as bad when they act unethically. Discussing how ethical behavior conflicts with self-interest in small groups may help students face the consequences of unethical behavior on society and avoid rationalization, at least while they are in school. However, I would not describe this as helping the student understand his or her true long-term self-interest. I would describe it as helping the students to see the costs of acting in their own short-term self-interest on dentistry and society, as well as helping them see that those costs accrue also to the student eventually.
There is, however, a psychological benefit to including self-interest in the ethical decision making process. We cannot ignore the role of self-interest in making decisions. We need to be aware of our self-interest to avoid acting on it unconsciously. A dentist who is unaware of his or her self-interest, or has learned to deny or repress it, is in danger of acting unconsciously and incongruently with ethical behavior because of the repressed struggle within. The dentist is more likely to act out against a patient or a situation if he or she cannot admit to the internal conflict. Once one is aware of self-interest, one can then identify the value of altruistic behavior and the cost of self-centeredness.
As Bertolami suggests, it is important for students and dentists to understand when their self-interest conflicts with the patient’s interest. Bertolami recommends avoiding those situations. If we take the example of the dentist who opens the groove in a tooth to be able to charge for a Class 1 composite instead of a sealant, Bertolami’s avoidance approach would be to refuse to do sealants. Avoidance may be appropriate in certain cases, but a better way of thinking about it is for dentists to try to find a way to meet the patient’s interests and their own at the same time. In our example, the sealants could be placed by an auxiliary (where legal), thus allowing the dentist’s time to be used on greater revenue-producing services. This is an example of how understanding the conflict between self- and patient’s interests can help a dentist find a solution that meets both interests as much as possible and avoids unethical behavior.
Bertolami’s article has stimulated me to consider including determining short-term and long-term consequences to self as a step in the ethical decision making process that I teach. However, the key is to find a way to incorporate a step that allows awareness of self-interest without encouraging unethical behavior.
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Faculty Member, Ethics Instructor, and Ethics Researcher, Dr. Ron Botto |
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TopAbstractDental student #1, michael...Dental student #2, siddhi...Dental student #3, victoria...Associate dean for student...Faculty member and ethics...Faculty member, ethics...References |
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If we taught ethics the same way we teach restorative dentistry, perhaps we wouldn’t have the problems with academic and professional integrity that Bertolami claims now exist. Restorative dentistry is taught with the groundwork laid in foundation knowledge about the body and tooth and associated biomedical attributes. This is followed by lectures on technique and application to tooth reconstruction and practiced in preclinical lab with regular feedback. When students are judged competent, they advance to the clinic where it is practiced with patients for a minimum of two years. Feedback is continuously provided. Competency is judged by the school before graduation and then judged again by the profession before the individual is licensed to practice. Throughout the dentist’s career, it must be reinforced by continuing education on a regular basis. This lifelong learning is even made enjoyable by teaching the courses in locations that are often enticing. The environment of the institution is oriented in such a way that restorative dentistry is clearly the mainstay of dental education. It is taught or referred to in each year of dental education. It is often the largest department in the dental school and has the most faculty. Furthermore, even if one isn’t a restorative dentist, all dentists are trained in restorative dentistry. Plus, most administrators are dentists and therefore also trained in restorative dentistry. It is obvious to the student that restorative dentistry is part of the everyday life of both the student and practicing dentist.
In comparison, let’s look at ethics. It is often only one course.30 It is often taught only in the final year as part of practice management, although in recent years there has been a shift to the first year of dental education. It is rarely, if ever, integrated into other courses in the curriculum. It is often oriented to "when you practice" rather than the ethical dilemmas students face each day in class, lab, and clinic.31 It is rarely taught or referred to in the clinic itself. Most of the faculty and administration were probably not formally trained in ethics while in dental school or, if they were, can’t recall what they were taught. Unlike faculty role-modeling in restorative dentistry, students don’t always perceive faculty as being positive ethical role models.31–34 Dental school ethics courses are often conducted by an outside ethicist rather than by dental faculty.30 Competency in coping with ethical challenges and dilemmas is not often tested in the same manner as other curricular competencies. Usually only the theoretical concepts of ethics, components of the dental practice act, and the rules and regulations of dental jurisprudence are assessed as foundation knowledge. Likewise, licensure exams focus on the legalities of practice rather than ethical issues. The message is clear: restorative dentistry is more important than ethics.
Dental faculty and administrators need to observe where ethics education ranks in their curriculum. It is doubtful that any other area has fewer hours devoted to it. The message is made even more clear: everything else is more important than ethics. If educators and organized dentistry feel ethics and ethical behavior are so important, than why is so little attention paid to it?
If the answer is that restorative dentistry, or any other aspect of dentistry, is more difficult to learn and practice than ethics, then why is concern expressed about student cheating and violations of licensure laws?35–40 While recent surveys have found that, on average, dental schools formally deal with one to two cases of violations of academic integrity per year,35 surveys suggest that those cases formally adjudicated represent merely the tip of the iceberg.36,38 Certainly, if the findings for medicine are any indication, the problem is significant.41–49 At least one study has shown a relationship between dental school behavior and that of private practitioners, suggesting that the issue certainly needs to be addressed.50 If attitudes and perceptions of cheating in dental schools are any indication, then there certainly is cause for concern.26–29,41,51–54
Students understand ethical dilemmas. As the student essays in this series attest, what they need is more experience and guidance in resolving them appropriately. This means understanding the values at stake, the processes of resolving the dilemmas, and the consequences of doing so ethically, both personally and professionally, both short-term and long-term. I believe that this is what Bertolami is actually proposing when he advocates the process of reflection that hopefully will lead students to an understanding of what behaviors are in their best self-interest. Unfortunately, the use of the term "self-interest" ("enlightened" or not) is traditionally considered to be the antithesis of altruism, too easily misapplied, and serves as a convenient rationalization for unethical behavior. For values to be strong and consistent, they need to be personalized and internalized; and the internalization needs to be by way of reflection rather than just mimicking the behavior of others. The process of reflection can occur any number of ways, including contemplation, observation, critical thinking, questioning, and wrestling with dilemmas. This mental rehearsal would give students the best chance of successfully resolving ethical dilemmas and addressing the pressures of dental education. This allows students to practice recognizing, addressing, and appropriately resolving ethical dilemmas when they occur rather than avoiding them as Bertolami argues.
I feel there needs to be reform in dental education in three areas: curricular, attitudinal, and environmental. First, dental schools need to formalize entering the profession of dentist-in-training through ceremonies shortly after matriculation wherein the entire dental school community (students, staff, faculty, administration) recommit themselves on a yearly basis to behave honorably and professionally. Research has shown that white coat ceremonies similar to those in medical education are appearing in other health professions education programs.55 However, these white coat ceremonies are insufficient on their own.56–60 They need to be a starting point in the integration of ethics into professional student life, not a freestanding and one-time only event, if held at all.
Furthermore, while research on honor codes in undergraduate universities suggests that they can be controversial, generally they are viewed as beneficial in upholding academic integrity.49,61–69 Although honor codes are less prevalent in health professions education, they are considered desirable.41,47,49,52,70–75 Research has suggested that honor codes have an impact: dental students who attend an undergraduate college with an honor code have more rigorous standards about ethical behavior than those who don’t.70 It is time to extend the positive influence of professionalism into private practice by incorporating high ethical expectations during dental school through codes of professionalism that are a part of daily dental school life. In addition, as a critical part of an honor code system, there needs to be a fair and consistent, yet compassionate method to deal with honor code violations.21,24,26,76–80
Second, we need to reduce the stress and pressure associated with dental education81–87 through a reexamination of curriculum along with reduction in the competition among students to be number one. As one of our student authors states, service to others needs to be emphasized and rewarded; ethical behavior needs to be recognized and rewarded as well. Just as importantly, students need to be offered alternatives to cheating to address the threat of failing.
Third, we need to do more to teach ethics in a restorative-like fashion. That means there needs to be both lectures on foundation knowledge related to ethical principles and methods of ethical decision making and opportunities for students to practice applying these concepts and processes.58,88,89 The classroom component of ethics courses should employ liberal use of case studies and demonstrations of ethical behavior as it applies to classroom and laboratory behavior, as well as the dental clinic and patient care. This would be followed by laboratories where students could practice using the principles of ethics to respond to ethical dilemmas during small group discussions of case studies and by roleplaying. The final component of ethical education needs to occur in the clinic where students would practice behaving ethically with actual patients and receive daily feedback from faculty regarding the quality of their ethical behavior. To create an overall school environment that promotes ethical behavior, all participants in dental education (students, staff, faculty, administration) should function as positive ethical role models.
To extend the scope of ethics instruction throughout the school would require all staff, faculty, and administrators to be trained in ethics and be competent in its application and teaching methods. This would also mean that the school would regularly devote faculty and staff development time to ongoing training in ethics, and faculty would take an active and vocal interest in engaging in both teaching ethics and promoting research ethics as well as research about ethics.90–94 Ethics would become part of daily life for students, staff, faculty, and administration. Competency would be required for both graduation and licensure. In addition, following graduation, organized dentistry, through licensure boards, would require regular refresher courses in ethics taught in a similar small group, case-based, ethical dilemma-oriented fashion in order to maintain skills and promote growth toward mastery. Thus, ethics education would span all years of dental education and continue after graduation, making the dentist a lifelong learner of ethics and ethical behavior. And none of the above would be elective.
Commentary.
Bertolami’s criticisms of ethics education do not acknowledge current ethical teaching methods and do not address many of the positive and negative influences on ethical behavior in dental schools. In addition, his suggestions to make ethics a precurriculum or an elective course contributes even more to the disconnect about which he complains rather than solving the problem. A precurriculum on its own does little more than further distance ethics from day-to-day dental school life. A prerequisite could be an interesting and worthwhile concept, but only if it is used as a basis upon which to build a meaningful dental school ethics curriculum. Making ethics an elective course not only limits its impact to those who probably need it the least, but sends the untoward, almost unseemly message that ethics is optional.
In addition to the idea of a precurriculum, Bertolami’s other suggestions for improving ethics education are also controversial when viewed from the perspective of improving ethical behavior. As has been pointed out, the value of teaching ethics via small group discussion is already widely acknowledged. How widely practiced it is in dental education is unknown. The issue of "enlightened self-interest" is perhaps Bertolami’s most controversial idea. While we believe that students need to be aware of the potential conflicts created by their self-interest when making decisions, it is more debatable whether or not self-interest when "enlightened" is likely to result in ethical behavior as Bertolami claims.
Our student authors remind us of the competitive pressures to behave unethically. Dental educators need to seriously consider approaches that reduce stress and support students academically. As one of the student authors states, service to others needs to be emphasized and rewarded, and ethical behavior needs to be recognized as much as, if not more than, GPA. Just as importantly, students need to be offered alternatives to cheating that address the threat of failure. This would work best in an environment where the rules are clear and consistently enforced and efforts are made to address academic problems early and provide timely remediation. Other techniques to improve the ethical climate in schools that have been thoroughly discussed elsewhere include formalization of matriculation into the profession of dentists-in-training through ceremonies55 and implementation of honor codes in professional schools.49,61,63–69
Fear of punishment and its role in ethical behavior are important issues that have been raised by our student authors and deserve full discussion. Most students do indeed believe that fear is the best method by which to achieve ethical behavior. However, the role fear plays in ethics is not as uncomplicated as it may at first appear. To begin with, while many authors feel punishment is a strong deterrent to unethical behavior, others feel its role is limited.21,23,95–97 Pressure, stress, and fear cause much of the motivation to cheat. The fear of failure in students is great: fear of failing school, failing boards, failing to get into the postgraduate program of choice (or any postgraduate program), fear of failing to achieve the grades they feel that they must obtain, fear of failing to graduate on time, fear of failing to be the best or perfect. To use fear as a motivator of ethical behavior means that schools need to make the fear of getting caught cheating greater than the already substantial fear of failure, and they have to make the likelihood of getting caught high, which requires large allocations of resources. In the end, the result is not a desire to behave ethically, but a fear of getting caught cheating. Policing does not instill ethical beliefs or behaviors, but instills a great deal of thought being placed on how to not get caught. Furthermore, it does little to induce ethical behavior in private practice where there is no immediate proctoring.
We believe that a more appropriate alternative is to encourage ethical beliefs and behavior in students through discussion of ethical dilemmas, the ethical consequences of various behaviors, the ethical principles involved, and the methods of making ethical decisions. We are not suggesting that behaviors should not have consequences. Consequences are important, and there are repercussions when consequences are not appropriate or consistent,79 as was pointed out by one of our student authors.
We believe that instilling ethical behavior in students requires a system-wide approach, in contrast to Bertolami’s suggestions of a separate precurriculum or as an elective. Instead, we recommend formal ceremonies to emphasize the commitment to integrity and professionalism by all members of the dental school, honor codes to formalize that commitment, helping students deal with pressures to cheat, giving ethics the same educational importance as other fundamental areas of dentistry, and working with faculty, administrators, and staff to achieve mastery in ethics knowledge and behavior so they can serve as positive role models for students.
Bertolami’s article has stimulated a dialogue that has received too little attention in dental education compared to other areas of academia. Medical education has been addressing the issues of ethics education and ethical behavior far more than has dental education. While they may be no closer to solutions than dentistry, we can certainly learn from their attempts and reflections. It is time for dental education to show it values moral health as much as it does oral health.
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Acknowledgments |
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Footnotes |
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REFERENCES |
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H. M. Sharp, R. A. Kuthy, and K. E. Heller Ethical Dilemmas Reported by Fourth-Year Dental Students J Dent Educ., October 1, 2005; 69(10): 1116 - 1122. [Abstract] [Full Text] [PDF]
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