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The Ethical Climate in Academic Dentistry in India: Faculty and Student Perceptions

Key words: institutional ethics, dental, ethical climate, India

Submitted for publication 08/18/04; accepted 02/15/05

	Abstract

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The aims of this study were to describe both the ethical climate in a private dental institution in India and the possible influence of selected factors in influencing faculty and students’ perception of their institution’s ethical environment. The Ethical-Climate Questionnaire and the General-Health Questionnaire (GHQ-12) were completed by twenty-eight full-time faculty and forty-seven final-year undergraduate students. Results showed that, overall, the study population had a mixed opinion about the ethical climate in their institution. Psychological distress and academic experience played an important role in shaping the perception of institutional ethics among the study population. The results showed that there is a need for better communication of the institution’s ethical policies and better ethical training to help the faculty and students recognize their institution’s commitment to ethics.

Interest in ethics in institutions of higher learning including those in dental education has increased in recent years.^3,4 The reason behind this may be due to the assumption that ethics incorporated into individuals during their educational experiences will stay with them throughout life. It has been suggested in the literature that an institutional ethics audit is possible in a dental academic setting.⁵

	Weber’s Institutional Ethics Audit Model

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Weber’s Institutional Ethics Audit Model⁶ is a theoretical model that has been touted as an effective method to assess the ethical environment in an institution and to classify it into four types: Aethical, Compliance, Emerging Ethical, and Integrity firms. Aethical firms generally ignore the need to institutionalize ethics into the daily decision-making processes of their employees. Due to either a lack of attention or a lack of effort to institutionalize their ethical business behaviors, Aethical firms are highly susceptible to unethical practices by their employees. This is because there is a lack of fear of legal or social reprisal for unethical practices by the employee. The second type are Compliance firms, which are motivated by fear of legal or social reprisal and have recognized the need to institutionalize ethics to some degree within the organization. In the absence of reprisals, however, compliance firms may revert to the position of Aethical firms. Third, the Emerging Ethical firms attempt to create an ethical work environment. This may be due to internal pressure, fear of increased government regulations, observations of a competitor’s unethical actions, or rank and file directives that go beyond what is legally required for ethics compliance. Finally, the Integrity firms recognize the importance of ethical decision making and ethical behaviors in pursuing their economic goals. An Integrity firm is at the pinnacle level that all firms are attempting to reach. Once a firm’s position on the institutional ethics continuum is determined, efforts can be made within the organization to progress along the continuum towards this ideal. The Institutional Ethics Audit is designed to assess the firm’s location on a continuum and to provide information that may help the firm progress toward becoming an Integrity firm. The audit involves an evaluation of the firm’s ethical culture, ethics policy, enforcement mechanisms, and ethics training.

Evaluation of Ethical Culture
The first critical component of institutionalizing ethics is to evaluate the organization’s ethical culture. The organizational culture reflects the group’s shared values and beliefs and influences all aspects of operations within the organization. It also provides collective norms about what is and is not appropriate action. The Ethical Climate Questionnaire (ECQ) was developed by Bart Victor and John Cullen⁷ to assess the ethical climate in an organization. It can be used in an academic setting if "the company" relates to an individual school or college. The questionnaire is based on the assumptions that 1) each company or subgroup has its own moral character; 2) group members know what character is; and 3) group members can tell an outsider about their organization’s moral character in an objective way.

To conduct the audit, the questionnaire is administered to all members of the group. Individuals are asked to rate each statement on the survey on a scale of least to most descriptive. The statement in the survey that is most descriptive of the organization’s ethical climate receives seven points, and the least descriptive statement receives one point. Item points are then totaled, and ethical work values are matched with three new ethical work cultures: Universal Morality, Consensual Morality, and Self-Centered Morality. Each question is designed to be grouped into one of these three ethical work culture types. Once the questions are grouped, the total and percentage of points for each work culture type are calculated and the ethical work culture determined.

According to Weber, Universal Morality is the preferred ethical work culture. This type of culture allows one to be unconstrained by the organizational pressures to conform to standard operating procedures, limiting norms, or laws. In contrast, a Self-Centered Morality culture predominantly involves consideration of each individual’s self-interest and represents an unstable and underdeveloped set of values. In Consensual Morality, the most common type of ethical work culture, employees turn to leaders or to the guidelines advocated by professional associations to guide their decision-making practices. Statements concerning Self-Centered Morality in the ECQ talk about the self-centered approach to daily decision making, the tendency to put the institution’s interests before that of its employees, and the overemphasis placed on financial goals at the cost of human development. An Aethical firm thus resembles the Self-Centered Morality culture type. Statements on Consensual Morality talk about the strict adherence to established laws, codes, and standard procedures in the institution. A compliance firm thus resembles the Consensual Morality type. Statements concerning Universal Morality talk about the freedom given to employees to decide for themselves what is right and wrong and about the increased focus on human development. The emerging ethical firms are a cross between ethical values found in a Universal Morality type and Consensual Morality type; the integrity firm illustrates the Universal Morality ethical work culture.

Evaluation of Ethics Policy
When assessing a corporation’s ethics policy, three factors are evaluated: 1) type of ethical policy, 2) control approaches, and 3) communication. Clarkson and Deck⁸ identified three distinct ethical policy types: Codes of Conduct, Codes of Practice, and Code of Ethics. Each policy type differs from the others in its content and purpose and can be associated with the four types of firms along the continuum. Codes of conduct are the statements of rules intended to promote a sense of professional responsibility among the organizational employees and indicating for employees what is expected or prohibited behavior. Codes of Practice on the other hand are intended to empower the employee as an ethical decision maker and to identify for the employee the rule of thumb operating procedures of the organization. Codes of Ethics, the third type, identify the organization’s mission statement and are usually one component of the overall institutional plan in an academic setting.

Aethical firms resist efforts to develop a formal Code of Ethics and instead focus exclusively on economic responsibility of the organization. Compliance firms adopt a formal corporate ethics policy that spells out what should and should not be done for employees. They do so, however, to avoid a negative impact on the firm’s financial viability. Emerging Ethical firms aim to empower their employees as ethical decision makers and favor the Code of Practices. Integrity firms empower their employees regarding ethical decision making by developing a Code of Ethics.

The next step in assessing the corporate ethics policy involves determining the type of control approach adopted by the organization. The four approaches are: 1) the use of rules, 2) seeking advice, 3) act, then disclose, and 4) the use of guiding principles. Organizations that strictly control employees’ behavior develop rules to attain ethical employee behavior. Firms may soften the degree of imposed control by expecting the employees to seek advice before acting or to act ethically and correspondingly advocate the use of guiding principles. Aethical firms fail to promote any ethical control on their employees. Compliance firms, through codes of conduct, avoid negative consequences, legal repercussions, or government regulations by imposing strict rules to ensure ethics compliance. Emerging ethical firms, through codes of practice, exert control by requiring employees to seek advice or act and then disclose their actions. Integrity firms, through codes of ethics, entrust control to the employees after providing guiding principles detailing the firm’s ethical structure.

To make an ethics policy an integral part of an organization’s environment, it must be implemented and regularly communicated throughout the firm. Weber’s model suggests methods of communications such as periodic review, two-way communication, multilingual printing, etc. Aethical firms fail to communicate their policies because they generally do not have a formal plan. Compliance firms adopt, either intentionally or otherwise, a formal policy, but only communicate it through superficial channels like onetime company mailings, new hires, etc. Emerging ethical firms communicate their policy in a sincere effort to promote the importance of ethics in employee decisions and behavior. Integrity firms recognize the value of a dynamic ethics policy and clearly and regularly communicate and distribute it to all company employees.

Evaluation of Enforcement Mechanisms
While many firms have established departments, divisions, or ethics enforcement officers, a primary concern of the audit is to investigate the priority given to this function by the organization. Aethical firms have inadequate enforcement since the organization does not intend for enforcement to occur. Compliance firms provide periodic enforcement, through either a human resource department or a compliance officer, addressing either emerging social issues or new government regulations. Emerging ethical firms actively seek the proper enforcement personnel to better institutionalize ethics into employees’ daily decision-making processes. While Integrity firms formally entrust the enforcement of ethics throughout the organization to a high-ranking employee, they generally rely upon all employees to act ethically on their own. Nearly all firms with formal ethics policies have developed negative consequences to be imposed after the discovery of unethical behavior. Enforcement mechanisms include termination, suspension, demotion, probation, and appraisal comments. Certainly many of these mechanisms apply to both faculty and students in an academic setting. Aethical firms ignore sanctioning unethical conduct unless it serves the economic interests of the organization. Compliance firms tend to administer sanctions arbitrarily depending on the rank of the offender, the potential exposure to negative media publicity and/or the economic repercussions of the actions. Emerging ethical firms impose negative sanctions evenly and consistently upon all employees engaged in unethical behaviors. Integrity firms recognize the need for punishment to be imposed that corresponds to the infraction. However, an Integrity firm relies on the culture, policy, and training to minimize, if not eliminate, the need to impose negative sanctions.

Four possible incentives to promote ethical behavior within an organization are: recognition, appreciation, commendation, and monetary rewards. Aethical firms, structuring their compensation systems around economic measures, offer no recognition of positive rewards. Compliance firms attempt to promote incentives for ethical behaviors, but it is rarely monetary. Emerging ethical firms incorporate positive reinforcement techniques into their formal recognition of rewards. Integrity firms integrate ethical decision making and performance into employee appraisals in an attempt to influence promotion decisions and/or salary increases. Most dental schools have some type of positive rewards system in place. For students, dental schools may include ethical/professional behavior in the clinical grading process. In addition, students’ awards are a positive means of recognizing outstanding professional behavior. For faculty too, awards may be in place for similar reasons. In addition, academic promotion also reflects a positive reward system that encourages professional behavior and role modeling.

Evaluation of Ethics Training
The final area of the Institutional Ethics Model to be audited is employees’ ethics training. Training serves to support the general ethical culture and ethics policy by promoting an awareness of present and potential ethical dilemmas that may arise in the organization. It also helps to consider ethics when making daily decisions. More importantly, when an organization develops a quality training program, it sends a signal to all employees that the issue of ethics is highly valued by the organization, thus serving to further reinforce ethical behavior. This discussion of ethical training includes an evolution of the type of training and the training approach. Types of ethics training programs include seminars, internally conducted courses, courses conducted by external institutions, personal interviews, or orientations. Approaches for ethical training include rules and guidelines, case studies, decision-making frameworks, and cognitive approaches.

Aethical firms generally fail to provide any type of ethics training, whereas Compliance firms typically present general rules and guidelines on legal issues and government regulations through orientation sessions. Emerging ethical firms provide interactive and participatory seminars and courses exposing employees to utilitarian reasoning. Integrity firms invest considerable time and money in ethics education and training through case studies, challenging employees in their moral cognitive reasoning, or providing exemplary examples of ethical conduct.

The concept of institutional ethics is still in a state of infancy in India. This provides us with an excellent opportunity to shape and direct the course of its future growth. This, however, needs to take the socioeconomic and cultural factors of that region into consideration when formulating strategies. Ethics among institutes of medicine is all the more relevant as they directly concern the lives of millions of people who utilize their services. However to date, no study on institutional ethics in a dental school setting has been reported in India.

Accordingly, to address this gap in our understanding of the ethical environment in dental schools, the objectives of this study were to:

1. describe the ethical climate of a private dental institution in India using the Ethical Climate Questionnaire;
   
2. describe the possible influence of selected factors on the perception of institutional ethics; and
   
3. identify whether students hold a perception of the institution’s ethical climate that differs from that of the faculty.
   

	Materials and Methods of This Study

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This study was conducted in the Manipal College of Dental Sciences, Manipal, India, which is a constituent college of the Manipal Academy of Higher Education, Manipal, a privately owned self-financing university. Established Codes of Conduct and a Code of Ethics prescribed by the university were in place in the study institution.

Prior permission was obtained from the dean for conducting this study, which is the standard procedure for approval of research protocols in our institution. The Ethical Climate Questionnaire (ECQ), developed by Victor and Cullen, along with the General Health Questionnaire (GHQ-12), was distributed to the full-time faculty with printed instructions for completion. The Ethical Climate Questionnaire (ECQ) and the GHQ-12 were also distributed to final-year students to gain an additional source of institutional ethics perception. The GHQ-12, a widely applied instrument to indicate psychological distress, is the short form of the General Health Questionnaire (GHQ),^9,10 designed by Goldberg as a self-administered instrument for use in community settings. The GHQ-12 is designed to detect possible psychiatric morbidity in the general population. The questionnaire is based on twelve questions, which ask informants about their general level of happiness, depression, and anxiety and sleep disturbance over the past four weeks. Two methods of scoring are used. In the Likert method, values of 0-1-2-3 are assigned to the columns (total score range 0–36) with a higher score indicating greater distress. The second method is the Bimodal method, which assigns values of 0-0-1-1 to the columns (total score range 0–12) and chooses a cut-off score that dichotomizes the population into "cases" and "normals."

The Likert method was used in this study. The twelve items were: I am able to concentrate, I have lost much sleep, I am playing a useful part, I am capable of making decisions, I am under stress, I could not overcome difficulties, I enjoy normal activities, I face up to problems, I feel unhappy and depressed, I am losing confidence, I think of myself as worthless, and I feel reasonably happy. The responses to these questions were: Less than usual, No more than usual, Rather more than usual, and Much more than usual. A preaddressed return envelope was included for confidentiality. In addition to these questionnaires, information was collected about the respondent’s age, gender, and academic experience and whether the respondent studied dentistry in a government or private institution. The academic experience was classified as zero to five years, six to ten years, and greater than ten years. A telephone number was also provided for respondents to clear any doubts and confusion regarding the questionnaire. A cut-off date was announced for receipt of the completed questionnaire after which no further forms were accepted.

Chi square test was done to test the overall association between each independent variable like graduating college, gender, academic experience, and stress and the three dependent variables (Self-Centered Morality, Consensual Morality, and Universal Morality). Chi square test was also done to test the variations of each dependent variable in relation to the independent variables. A p value of 0.05 was established for statistical significance. Cronbach’s alpha was used to measure the internal consistency for the ethical climate questionnaire. All the data analysis was done on SPSS (Version 6) software package.

	Results

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Out of a total of thirty-eight full-time faculty, twenty-eight completed the questionnaires (74 percent). The age of the faculty respondents ranged from twenty-seven to fifty-seven years. Among the twenty-eight respondents, eight were females and twenty were males. Six of the respondents had completed part or all of their dental education in a government institution. Thirteen respondents had zero to five years of academic experience, six had six to ten years, and nine had more than ten years of academic experience. Cronbach’s alpha (Reliability Coefficient) was used to measure the internal consistency of the Ethical Climate Questionnaire, and the coefficient was calculated at 0.76.

The total and percentage for each work culture type was calculated as follows. In Table 1, for example, six subjects rated statement #1 as being the most descriptive, so that statement received 42 points (6x7); two subjects rated it as being the second most descriptive (2x6); five subjects rated it as being the third most descriptive (5x5); five subjects rated it fourth most descriptive (5x4); five subjects again rated it fifth most descriptive (5x3); three rated it the sixth most descriptive (3x2); and two rated it the seventh most descriptive or least descriptive (2x1). Item points were then totaled: 42+12+25+20+15+6+ 2=122 (Table 2). Similar totaling was done for all the statements. Then each statement’s total was grouped under its respective work culture type. All the totals of each work culture type were then added (Table 3). For the faculty, it was 908, 956, and 719 for the three work culture types, respectively. These three were added to form the grand total (which was 2583), out of which the individual percentages of each work culture types were calculated (Table 3).

The ECQ was also distributed among the sixty-eight final-year students, and forty-seven returned completed questionnaires (69 percent). The students also perceived their institutional ethics as having an equal influence of all the three types of work cultures: Self-Centered Morality at 35.42 percent; Consensual Morality at 34 percent; and Universal Morality at 30.57 percent (Table 4).

The GHQ-12 scores among the faculty ranged from a low of 7 to a high of 33. For the sake of convenience, the study population was dichotomized into two groups with one group consisting of respondents with the four highest GHQ-12 scores obtained, which were 19, 21, 29, and 33 and the rest being in the other group. The high GHQ-12 score group had four members, and the other group had twenty-four. This was done to facilitate a meaningful statistical comparison between the two groups and to prevent the dilution of any differences between the two. When comparison of faculty’s perception of institutional ethics was done between the two groups, it was observed that the high GHQ-12 score group perceived the ethical culture of the institution as less ethical, compared to the "others" group. This was reflected by the perception of Self-Centered Morality that increased from 32 percent in the "others" group to 41.07 percent in the high GHQ-12 score group; this difference was statistically significant. Also, the perception of consensual morality decreased from 39.6 percent in the "other" group to 34.8 percent in the high GHQ-12 score group respectively, but this difference was not statistically significant. Overall, the difference in perceptions of institutional ethics between the two GHQ-12 groups of faculty was found to be highly significant (Table 5).

Similar analysis was done among the students as a group. GHQ-12 scores among students ranged from a low of 3 to a high of 32. Overall, the differences in perception of institutional ethics between the high and the low GHQ-12 groups were found to be statistically significant (Table 5). No statistically significant differences in perceptions of institutional ethics were observed when the responses of males and females were compared (Table 2).

	Discussion

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A recurring theme in the literature on ethical climate is whether unethical behavior is more a function of personal or organizational characteristics.¹¹ There is general consensus among scholars that both factors impact unethical acts. However, an implicit assumption of research on ethical climate is that the way an organization is structured can influence the display of ethical behavior among organizational members. In other words, it is not just a "few bad apples" that cause ethical problems in organizations.¹¹ However, there have not been investigations into the relative impact of personal characteristics on ethical climate perceptions. Although a few studies have been done to examine ethical subclimates within a single organization, no such study has been reported from a dental institution.^12,13

This study was conducted among the faculty of a private dental training institution as it was felt that they were the business equivalent of employees in an academic setting. Students were also included in this study to provide additional data on perceptions of institutional ethics. This study showed that the ethical environment can be assessed by the Ethical Climate Questionnaire (ECQ) in a dental academic setting. The results indicated that faculty perceived the school’s ethical culture to have a nearly equal influence of all the three types of morality (Self-Centered, Consensual, and Universal Morality) based on the percentage of overall points. It was also observed that the perception of institutional ethics among the faculty and the students was not uniformly distributed among all the members. Subgroups within the faculty and among the students based on their personal characteristics were found to share different perceptions about their institutional ethics.

The data on faculty were examined by gender, academic experience, graduating school, and psychological distress to determine if these factors influenced faculty members’ perception of their institutional ethics.

It was observed that the more experienced faculty members perceived that their institution’s environment was more ethical than did junior faculty. An increased understanding and acceptance of their institution’s daily decision-making processes and work culture along with an increased wisdom and mental maturity that come with experience may be the reasons for this perception.

Levels of psychological distress among faculty and students were assessed to determine whether it affected their perception of institutional ethics. It was found that the faculty and students who reported higher GHQ-12 scores perceived the school’s environment as less ethical than did those with lower GHQ-12 scores. Factors like gender and graduating school of the faculty did not influence perceptions of institutional ethics.

Since there was no one particular type of morality that exerted a dominant influence on the institution’s daily decision-making process, an additional review of the school’s ethics policy, enforcement mechanisms, and ethics training was performed. This review revealed that the dental school had well-established ethics policies and training programs.

A formal code of ethics as well as a code of conduct that described expected behavior and spelled out the consequences of noncompliance already existed in the study institution. The ethics policy was communicated throughout the institution through university circulars, mailings addressed to all the faculty members, etc. on a regular basis. Extra emphasis was placed on communicating the ethics policy and codes of conduct to new hires. Instances of exemplary ethical and professional behavior by students and faculty were highlighted in monthly university newsletters to motivate others to do the same. Enforcement of the ethics policy was delegated to the dean and the senior faculty. Sanctions for unethical behavior ranged from issuing memos and reprimands to suspension and termination. These were characteristics of Compliance firms. A teacher learning program was held every year in which, among other things, the institution’s ethics policy was explained to the faculty during orientation sessions and interactive seminars. A Best Teacher Award was also given out each year to a faculty member after receiving input from the students. A Best Outgoing Student Award was also given each year based on academic performance and professional and ethical behavior. Incentives for ethical behavior ranged from commendations to influencing promotion decisions or salary increments for the faculty. These were characteristics of emerging ethical firms.

These findings indicate that, on an institutional ethics continuum, the dental school studied had the characteristics of both compliance firms and emerging ethical firms. The results of this study showed that both faculty and students varied in their moral and ethical perception of their institution despite the existence of definite ethics policies and training programs. The overall process of distribution and communication of ethical policies may have to be enhanced or altered substantially to enable the faculty and the students to recognize their institution’s commitment to ethics.

	Conclusions

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The following conclusions may be drawn from this study:

• Faculty and students perceived that the school’s ethical culture was equally influenced by Self-Centered, Consensual, and Universal Morality.
  
• On the whole, the perceptions of institutional ethics were similar among faculty and students.
  
• Subgroups among the study population, based on some of their personal characteristics, were found to have differing perceptions of institutional ethics.
  
• Factors like academic experience and psychological distress influenced faculty perceptions of institutional ethics.
  

	Acknowledgments

 
The author would like to thank Dr. G. Subraya Bhat, Professor, Department of Periodontics, Manipal College of Dental Sciences, Manipal, and Mr. Sangam D.K, Biostatistician, J.J.M. Medical College and Hospital, Davangere for their valuable support.

	Footnotes

 
Dr. Acharya is Assistant Professor, Department of Community Dentistry, Manipal College of Dental Sciences, Manipal, India. Direct correspondence and requests for reprints to him at 1-2-50 B Bhagyashree, Opposite Indira Shivarao Polytechnic College, Kunjibettu, Udupi 576 102, Karnataka State, India; 0820-252-7031 phone; 944-812-7031 mobile; shashidhar_acharya{at}yahoo.com.

	REFERENCES

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