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Why Our Ethics Curricula Do Work

Key words: ethics, dental curricula

Submitted for publication 11/04/04; accepted 11/17/04

	Abstract

Top Abstract Cheating would be rare... Dental students cheat even... Ethics courses don’t work... No one has ever... References

 
The purpose of this article is to respond to Dr. Charles Bertolami’s article "Why Our Ethics Curricula Don’t Work" in the April 2004 issue of the Journal of Dental Education. This article analyzes the arguments put forth by Bertolami and challenges his assumptions and conclusions. Several examples are given of the ways in which our current ethics curricula do, in fact, work.

1. Cheating would be rare if ethics courses worked.

2. Dental students cheat even after taking ethics courses

Therefore:

3. Ethics courses don’t work to change behavior. And

4. No one has ever done the right thing because of taking an ethics course.

These are quite remarkable conclusions given the absence of any empirical research in his article, and although Bertolami acknowledges that he lacks the scientific goods, he nonetheless feels confident that his conclusions are "surely evident."

Well, let’s take a look.

	Cheating would be rare if ethics courses worked.

Top Abstract Cheating would be rare... Dental students cheat even... Ethics courses don’t work... No one has ever... References

 
First of all, cheating is only one of several bad behaviors discussed in a dental ethics course. I don’t have the numbers on this either, but based on my experience as an ethics instructor and from reviewing dental ethics courses at other institutions, I can say that cheating is rarely an important topic in these courses because it is a rather obvious ethical transgression. Other, more important ethical issues that pertain to the patient care environment are addressed in these courses, such as keeping patient information confidential, fully informing patients of treatment risks and benefits, objectively criticizing the work of other dentists, declining to provide treatment when certain types of procedures are not warranted, and respecting the autonomous choice of patients. These issues and behaviors are far less obvious to novice dentists and thus are the focus for ethics courses in many dental schools. The fact that cheating behavior is more easily discovered than the poor execution of these other behaviors does not necessarily make it a good barometer for pedagogical success.

Secondly, Bertolami’s observations about the influence of ethics courses on cheating are very much like saying that traffic violations would be rare if everyone had to pass a test to obtain a driver’s license. The fact is that everyone who has a license has indeed learned the rules of the road, at least enough to pass a written test, yet traffic violations are still quite common. Now, no one would suggest that we abandon the driving test based on the prevalence of traffic violations, yet this is exactly what Bertolami advocates. It should be obvious to anyone that, while knowing the rules of the road is not a sufficient condition for avoiding traffic violations, it certainly is a necessary one. One has to minimally know that a red light means "stop" to avoid committing the violation of not stopping at a red light. Whether one chooses to stop or not is quite another question (more on this later). It seems entirely reasonable that millions of traffic violations have been prevented simply by having motorists learn the rules of the road; the fact that some people continue to make these violations out of either ignorance or willful neglect says nothing about the value of driving tests.

	Dental students cheat even after taking ethics courses.

Top Abstract Cheating would be rare... Dental students cheat even... Ethics courses don’t work... No one has ever... References

 
No doubt this statement is true in part, but based on my personal experience, I am willing to bet that most instances of cheating in dental school occur in didactic courses, usually in the first two years and before dental students take ethics courses, which are often taught in the third and fourth years of school as they are at UCSF. Does the incidence of cheating decrease after a course in ethics? Increase? Stay the same? These are interesting empirical questions that deserve at least some investigation if one is to accept Bertolami’s claim. If we found that the incidence of cheating decreases significantly (though not totally) following a course of ethics, wouldn’t we be encouraged about the success of such courses? Even if the incidence increased or stayed the same, one would have to show that cheating behavior was specifically addressed in these courses, which, as I contend, is usually not the case.

	Ethics courses don’t work to change behavior.

Top Abstract Cheating would be rare... Dental students cheat even... Ethics courses don’t work... No one has ever... References

 
Given the problems underlying Bertolami’s first two assumptions, it would be difficult for anyone to accept the conclusion that ethics courses don’t change students’ behavior. Bertolami would have us believe that ethics courses have to be nearly 100 percent successful in altering cheating behavior to be of value. In his words: "if our ethics curricula were working, wouldn’t such dishonesty be relatively uncommon?" But as I have already argued, this is, in general, not a focus of ethics curricula and is an unrealistic and unnecessary expectation of a course in dental ethics. Wouldn’t we all be happy with even a slight dip in cheating incidents due to such a course? More importantly, what of the other behaviors that dental ethics educators work so hard to improve? Do our ethics courses change the way dental students behave in relation to the behaviors listed above? Are students less likely to divulge confidential information about a patient, more likely to do a better job of informing patients, less likely to criticize a colleague unfairly, or less likely to abuse the autonomy of a patient? The answers to these questions are the real measure of a course in ethics.

One could easily survey dental students and ask them if they have ever changed the way they interact with a patient or colleague based upon what they learned in their ethics course. One might even legitimately ask if they felt they would act differently in the future based upon what they had learned. Or one could simply consult the existing literature on the subject and discover that there have been empirical studies showing that ethics education has a real effect on the way dental students think about ethical issues.^2–6 Even without the numbers, it is not hard to imagine that any student who has learned that one must always present treatment alternatives to a patient, a rule that he or she previously might have been ignorant of, would make an earnest effort to do this in every patient encounter thereafter. His or her behavior would indeed change simply by going from a state of ignorance to one of knowledge in much the same way that a motorist from the United States would quickly change his or her driving behavior in England and make the effort to drive on the other side of the road. To use Bertolami’s own analogy, it is my contention that one has to know the rules of a game in order to participate at any meaningful level.

There is little doubt in my mind that dental student behavior is changed by teaching students the dental ethics "rules of the road," just as their behavior is changed by learning that some patients are allergic to penicillin (how often do students make this prescribing error after coming to know this?). Dentists have ethical obligations that are as rule-like as anything found in a driving exam. In fact, I give my students a list of more than two dozen ethical obligations in my ethics courses. Is this sometimes boring and dry stuff to teach? You bet it is. But each obligation or rule is a necessary condition of knowledge, the bedrock of more interesting and subtle discussions of ethical dilemmas.

Bertolami also criticizes ethics curricula by claiming that ethics courses rely upon the use of ethical codes and abstract ethical principles. My consultation over the years with colleagues who teach ethics at other dental schools and who teach others how to teach, as Tom Hasegawa and David Ozar have for years, indicates that the use of principles and codes to teach ethics is quite rare. In the courses I have taught at UCSF, ethical principles and codes are a minor part of the course and are included only because I know they will be a part of our students’ state board examination. Instead, it is generally accepted within this field that the engagement of students in the discussion of ethical dilemmas is a much more interesting and effective way to teach and has been used for several years. The major textbook in the field of dental ethics, Ozar and Sokol’s Dental Ethics at Chairside,⁷ barely mentions ethical principles. Still, Bertolami is justified in asking the same question about the use of ethical dilemmas in a course on dental ethics: does this strategy ultimately change ethical behavior? I offer the following thoughts derived from personal experience, but again, I do not have the data to empirically support these observations:

1. My experience in conducting discussions with dental students about ethical scenarios shows that students are genuinely quite surprised to find that their peers do not necessarily think the way they do, something that might not be discovered without the opportunity to voice these opinions in both small and large groups. This is an essential awareness needed for the ethical development of young dentists: they must first see that relying on their own values, beliefs, and intuition does not necessarily guarantee a good and reasoned ethical choice.
   
2. Similarly, when asked to vocalize their own opinions, students are forced to clarify their own values and beliefs and in some cases defend their opinions, something they may have never been asked to do about ethical issues. This is an invaluable exercise in their development, and I have had several dental students and practicing dentists thank me for challenging them in this way.
   
3. Lastly, when these discussions are led in a skillful manner, students have an opportunity to see how experienced ethicists reason through problems—in effect, a skills demonstration much like they get in a preclinical technique laboratory. Most importantly, they get to see that there are, indeed, "right" answers to ethical problems and that it is not just "a matter of opinion." More than a few students have made this comment to me at the beginning of a course. For ethics to have relevance, it must provide answers; fortunately, it can and does.
   

Is it not entirely possible that a skillfully led discussion on an ethical scenario could succeed in affecting future behavior? Shouldn’t students be able, minimally, to mimic the behavior discussed in the scenario when the same things happen to them in a clinical situation or, ideally, reason by analogy when the circumstances are slightly altered? Using the ethical reasoning protocol advocated by Ozar and Sokol and very much a part of the courses my colleagues and I teach, shouldn’t students have the skills to work through ethical problems on their own? To deny this would mean to say that students regularly fail to use the hand skills that we teach them in preclinical laboratory technique courses once they are in the clinic.

From my experience, there is little doubt that students are well prepared to work through ethical problems on their own by a course utilizing both the "rules of the road" and by thoughtfully led discussions of ethical scenarios.

	No one has ever done the right thing because of taking an ethics course.

Top Abstract Cheating would be rare... Dental students cheat even... Ethics courses don’t work... No one has ever... References

 
Here again we are asked to accept a conclusion with absolutely no evidence, and while it seems easy to dismiss this sort of sweeping and speculative generalization, there is an important point here. It is my belief that Bertolami assumes that no matter how well prepared, no one has ever chosen to do the right thing because of taking an ethics course. Here, at last, we can move on to consider the other necessary condition needed to ensure ethical behavior and wonder if we can achieve this condition in a course in ethics.

Knowing dental ethics and being ethical are two different things, and my colleagues and I who teach dental ethics are all keenly aware of this. It is something that I routinely emphasize to students. In fact, there is a significant body of literature, both philosophical and psychological, that attempts to answer the question: why do people who know better act so badly at times? My contention here has been that people, at the very least, have to know better in order to act better. When I teach dental ethics, I am under no illusion that I can make a saint out of a devil. What I do know is that it is unrealistic to expect good behavior from students who are ignorant of the basic ethical obligations of their chosen profession. This is exactly why state board-mandated remedial ethics courses make sense: the state can be assured that future incidents of unethical behavior are not a result of mere ignorance. And, in this sense, dental ethics courses, as they are now taught, are essential and invaluable. Could they be better? Absolutely. Could they actually provide students with the moral courage needed to make the right choices when they already know right from wrong? This is an open question and one that deserves some empirical research.

The true value of Bertolami’s article is that it stimulated discussion on what exactly we need to do to help students and colleagues make the right decisions, when they otherwise would not, even though they know better. It is a timely question and perhaps his provocative proposal will do the trick. We will have to wait for the evidence.

	Footnotes

 
Dr. Jenson is Associate Clinical Professor and Interim Chair, Division of Clinical General Dentistry, University of California, San Francisco, School of Dentistry. Direct correspondence and requests for reprints to him at University of California, San Francisco, School of Dentistry, 707 Parnassus Ave., Box 0758, San Francisco, CA 94143; 415-502-2289 phone; 415-476-0858 fax; jensonl{at}dentistry.ucsf.edu.

	REFERENCES

Top Abstract Cheating would be rare... Dental students cheat even... Ethics courses don’t work... No one has ever... References

 

1. Bertolami CN. Why our ethics curricula don’t work. J Dent Educ 2004;68(4):414–25.[Abstract]
2. Bebeau MJ. The defining issues test and the four-component model: contributions to professional education. J Moral Educ 2002;31(3):271–95.[Medline]
3. Bebeau MJ. The impact of a dental ethics curriculum on moral reasoning. J Dent Educ 1994;58(9):684–92.[Abstract]
4. Bebeau MJ. Ethics for the practicing dentist: can ethics be taught? a look at the evidence. J Am Coll Dent 1991;58(1):5,10–5.
5. Bebeau MJ. Teaching ethics in dentistry. J Dent Educ 1985;49(4):236–43.[Abstract]
6. Bebeau MJ, Rest JR, Yamoor CM. Measuring dental students’ ethical sensitivity. J Dent Educ 1985;49(4):225–35.[Abstract]
7. Ozar DT, Sokol DJ. Dental ethics at chairside: professional principles and practical applications. St. Louis: Mosby, 1994.

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