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Abstract
Walker’s comprehensive review of claims of gender difference and gender bias in moral cognition concluded 1) that gender explains a negligible amount of the variability in moral reasoning development, 2) that accumulated evidence does not support claims of gender polarity in moral orientations (i.e., an ethic of care and an ethic of justice), and 3) that future research should focus on the range of psychological processes that engender moral maturity. This study examined whether male and female predoctoral dental students who completed an ethics curriculum grounded in Rest’s comprehensive model of moral functioning differed on measures of four capacities: moral sensitivity, moral reasoning, moral motivation, and moral implementation. From archival data at the University of Minnesota School of Dentistry, data on sixty females and sixty males were randomly selected from five cohorts (n=386) who completed an ethics curriculum and outcome measures of the four capacities between 1996 and 2000. Gender differences were not apparent for a measure of moral sensitivity, but were evident for one of the moral reasoning indices, for the responsibility dimension of moral motivation, and for the measure of moral implementation. Implications are drawn for future research and for professional ethics education.
Claims of gender difference and gender bias have generated considerable interest over time. In philosophy, the notion that men are more rational while women are more caring can be traced to ancient philosophical theories of morality,1 albeit without empirical evidence. New versions of these ideas have resurfaced in feminist theories and are used to argue for a more care-centered profession.2–4 In psychology, with its emphasis on empirical evidence, the claims that Kohlberg’s theory of moral judgment development missed or misconstrued women’s different voices on moral issues, characterizing them as morally deficient, generated a great deal of discussion and decades of studies designed to provide empirical support for the claims.5,6 Meanwhile, beliefs about the differential impact of women—especially in the more traditionally male-dominated professions such as law, medicine, dentistry, and engineering—surfaced as they began to recruit more women.
The purpose of this study was to examine whether male and female predoctoral dental students who have benefited from an ethics curriculum differ on measures of the four capacities considered necessary conditions for moral behavior. Specifically, we asked the following research questions: 1) Is there gender difference on students’ moral sensitivity scores (measured by the Dental Ethical Sensitivity Test [DEST] total score)? 2) Is there gender difference on students’ moral reasoning scores (measured by Defining Issues Test [DIT] schema, N2 scores, and type indicator)? 3) Is there gender difference on students’ moral motivation scores (measured by the Professional Role Orientation Inventory [PROI] authority and responsibility scales)? 4) Is there gender difference on students’ moral implementation scores (measured by the Professional Problem Solving [PPS] test)?
Because claims of gender difference and gender bias seem to resonate with people’s lived experience, our first step before reporting on our study is to provide an overview of the empirical evidence supporting or disconfirming the presence of gender difference and gender bias in psychological theories of moral development. We follow this with a review of available evidence suggesting gender difference in ethical abilities and areas for further study. After a review of changes in the status of men and women in the dental profession, we summarize the evidence of gender difference in relationship-oriented qualities thought to enhance the dental profession as greater gender equity is achieved within it.
Gender Bias and Difference
The most substantive recent review offers little empirical support for the notion that Kohlberg’s theory is biased against women7 or that women and men differentially prefer care and justice reasoning.8 With respect to gender difference in moral judgment, researchers have used either Kohlberg’s Moral Judgment Interview (MJI) or the more widely used and easily scored DIT.9,10 Researchers consistently find either no difference or that women have a slight but statistically significant advantage over men on the DIT. Thoma’s meta-analysis of DIT studies concluded that the amount of variance accounted for by gender was less than 1 percent.11 However, since moral behavior is not only a function of moral reasoning—Rest argues for at least three other capacities that give rise to behavior—there may very well be important gender difference in other components of morality.12 Thus, the objective of this study was to explore gender difference on measures of other components of morality.
Gender Bias in Dentistry
In 1976, women made up only 1 percent of dentists in the United States, compared with estimates of 2 percent of lawyers, 5 percent of physicians, and 6 percent of pharmacists. A belief that women would enhance professions through their relationship-oriented qualities was used as an argument for the inclusion of women in such male-dominated professions.13 Women, it was thought, were more caring, sensitive to others’ needs, empathic, and concerned about relationships. Sex-role stereotyping was thus actually used as an inducement to recruit more women to the professions. Similarly, sex-role stereotyping was used to argue that women lacked the necessary strength and stamina for some aspects of the dental profession, like oral surgery.14 However, even early studies of personal attributes of male and female dental students suggested that women recruited to the profession were more similar to than different from their male colleagues,15,16 though some differences were noted. For instance, Coombs found that women dental students expressed far greater preference (three to one) for working with the aged than did male students and that women alone expressed an interest in team dentistry.17,18
Whether male and female dentists actually differ on relationship-oriented qualities has not been extensively studied. However, a recent study suggests that patients’ preconceived gender-based expectations and assumptions may influence rapport and communication between dentists and patients.19 Ultimately, a dentist’s actual relationship-oriented qualities and competencies may not be able to overcome a patient’s gender bias. Nonetheless, competence in recognizing the bias may enable a dentist to adopt strategies to meet the patient’s perceived need.
Gender Difference in Measures of Ethical Development
Rest’s Four-Component Model of Morality (FCM) describes four processes—moral sensitivity, moral reasoning, moral motivations and commitment, and moral implementation—thought to be independent and necessary contributors to moral behavior.12 The four components20 as applied to the professions are operationally defined in Table 1. The model is helpful in reflecting on the reasons for the moral success or failure of dentists disciplined by a licensing board; it also functions as a basis for a program of ethical study.21,22 In fact, for three decades, the FCM has served as a basis for the design of ethics education in the professions (e.g., nursing, medicine, dentistry, law, research ethics23–25), in business ethics,26–28 and in elementary education.29 Whereas much of the literature in professional education focuses on the effects of ethics education on moral judgment,24 considerable effort has been expended to measure and teach the other three components. For example, in the past twenty years, eighteen instruments have been designed to assess moral sensitivity in seven professions.30 With respect to assessment of moral motivation in the professions, two measures have been designed and validated (the PROI31 and the Professional Decisions and Values Test32) to assess professional identity formation. Further, work is currently under way to study stages and transition phases in professional identity formation.33–35 With respect to moral implementation, educators have described strategies to measure the fourth component in the context of dental education36 and research ethics education.25
The four components of morality
Moral sensitivity
Based on early observations of gender difference in dentistry’s measures of moral sensitivity, Bebeau and Brabeck hypothesized that gender difference was more likely the result of differential socialization (women are socialized to be more empathic, altruistic, and nurturing) rather than differing moral orientations and therefore would be apparent on measures of moral sensitivity.37 Further, they speculated, differences in moral sensitivity may have been a function of differences in the preparation and/or selection of women who entered what was at the time a male-dominated profession (on average, the ratio of men to women in 1982, when the data were collected, was 3 to 1). Since Bebeau and Rest’s initial work on the measurement of moral sensitivity,38 You and Bebeau have identified eighteen measures designed to assess moral or ethical sensitivity across a variety of professions.30 Of thirty-four studies investigating gender difference in moral sensitivity, the findings have been equivocal: three studies26,37,39 supported gender difference in moral sensitivity, and five did not.27,28,40–42
A recent meta-analysis supported the presence of gender difference in moral sensitivity.43 Of the sixty-one studies identified, fifty-eight were theoretically grounded in Rest’s definition of moral sensitivity, but only nineteen contained sufficient statistics (e.g., means, standard deviations, and sample size by gender) to meet criteria for inclusion in the meta-analysis. The results indicated an average effect size of 0.25, favoring women, that was rather small, though the substantial variation in effect sizes (−0.03 to 0.53) suggested the presence of moderator variables. Although the number of studies that could be included in the meta-analysis was limited, variation in the observed effect sizes could not be attributed to differences in participants’ educational level, the utilized measure of moral sensitivity, or the publication format in which the study was reported. Thus, gender difference in moral sensitivity appears to be consistent across various levels of participants’ education regardless of the instrument used to assess moral sensitivity or the format in which the research was reported.
Moral reasoning
Whereas gender difference (favoring women) appears to account for less than half of 1 percent of the variability in moral reasoning,7,11 gender difference in the professions appears to be more robust.24 In recent years, moral reasoning researchers have examined patterns of consolidation and transition in moral judgment development. Research has indicated that individuals use moral concepts differently as they cycle through periods of consolidation and transition. As individuals move into periods of consolidation, the utility of moral stage information increases.44 In the DIT,10 the patterns of consolidation and transition are represented by type indicators (see Figure 1).45 In addition, one study found that the small positive relationship between the DIT and profession-specific measures of ethical concepts increases greatly when a developmental phase is included in the analysis.46 In other words, based on the type indicator, the consolidated status was associated with higher scores on the Dental Ethical Reasoning and Judgment Test, a profession-specific measure of ethical reasoning and judgment.47 To date, gender difference on the type indicators has not been investigated.
Seven hypothetical types in terms of development and consistency in moral reasoning
Type 1: Predominant in personal interests schema and consolidated.
Type 2: Predominant in personal interests schema, but transitional.
Type 3: Predominant in maintaining norms schema, but transitional; personal interests secondary schema.
Type 4: Predominant in maintaining norms schema and consolidated.
Type 5: Predominant in maintaining norms schema and transitional; postconventional secondary schema.
Type 6: Predominant in postconventional schema, but transitional.
Type 7: Predominant in postconventional schema and consolidated.
PI=Personal Interest; MN=Maintaining Norms; P=Postconventional
Moral motivation
In Kang’s review of the PROI,48 three studies were cited that investigated motivation (conception of a professional’s role and responsibility) in the context of professional practice. These studies indicated that role concept can be reliably measured and can be enhanced through education. However, to date, gender difference in role concept has not been investigated.
Moral implementation
Whereas profession-specific, norm-referenced measures of component four processes have not been designed and validated, educators do attempt to influence and to measure professional students’ ability to apply problem-solving and interpersonal skills (elements of component four) to the resolution of complex problems encountered in clinical practice. In medicine, for example, some of the performance-based assessments known as objective structured clinical examinations (OSCEs) have ethical issues embedded. Similarly, moral assessments may be reflected in performance on case presentations.23 To date, gender difference on performance-based assessments of component four processes has not been explored.
Methods
Rest’s FCM12 was used as the theoretical grounding for the dental ethics curriculum at the University of Minnesota School of Dentistry and for the design of the DEST,38 the PROI,31 and the PPS as measures of components one, three, and four, respectively. Use of these measures, together with the DIT,10 has been part of dental ethics curricula for over twenty years. Thus, it is possible to examine the presence of gender difference in measures of these students’ moral sensitivity, moral reasoning, moral motivation, and moral implementation.
For our study, the records of a total of 120 University of Minnesota dental students (sixty females and sixty males) were randomly selected from five cohorts (n=386) that graduated between 1996 and 2000 (to ensure equal representation of males and females from each cohort, twelve men and twelve women were randomly selected from each). Whereas twenty-five cohorts of students have completed the ethics curriculum since it was developed, these five cohorts (n=74–79 students per cohort) were selected for the following reasons. First, there were no major changes to the ethics curriculum during this time period, minimizing the potential impact that could be attributed to instructional differences. Second, Form A of the DEST was used for these five cohorts, minimizing the amount of training required to establish interrater reliability before rescoring of the DEST protocols. This step was deemed necessary as the DEST had initially been scored by multiple raters whose reliability had not been established prior to instructional feedback provided by practicing dentists. Third, the ratio between males and females had changed since Bebeau and Brabeck’s gender difference study was conducted in the early 1980s.37 Based upon the change in percentages of males and females at this institution (Table 2), ten years seemed to be an acceptable interval for replicating that study. Finally, a practical consideration entered into cohort selection. All DEST responses for these five cohorts had been transcribed whereas, in later years, the students were scored directly from taped responses.
Gender numbers and percentages for University of Minnesota predoctoral dental students, 1985–2007
The Measures
Moral sensitivity
The DEST Form A consists of four scenarios in which ethical issues are embedded.38 The scenarios were developed from actual reports obtained from experienced dentists concerning the most common ethical problems they encountered in their practices. In the DEST protocol, the participants listen to an audiotaped conversation between a dentist and patient and, at a certain point, are asked to take the role of the dentist and interact with the patient as they see fit. Following that, the participants are asked to answer a series of probe questions designed to elicit their interpretation of the situation. The participants’ responses are audiotaped and transcribed for scoring. The responses are scored by assigning ratings from 1 to 3 to indicate the degree of recognition of each of thirty-four ethical issues.
The issues reflect two dimensions: sensitivity to the characteristic(s) of the patient and sensitivity to the responsibilities of the dentist. Judgments are based neither on the quality of the solution offered nor on the quality of the interpersonal interaction skills displayed, but upon the extent to which what is said reflects recognition of the issues. In validation studies, measures of internal consistency produced Cronbach alphas ranging from 0.70 to 0.78. Test-retest correlation was 0.90. Evidence of validity included both convergent and discriminant validity. The measure has a correlation of 0.69 with the practitioner’s intuitive ranking of protocols and correlations of only 0.20 to 0.40 with measures of verbal fluency, technical knowledge, and word count of the subjects’ responses.37 In addition, moral sensitivity as measured by the DEST has been shown to improve with instruction,37 and students and practitioners vary greatly in their ability to recognize the technical problems within the profession.36
Moral reasoning and judgment
The DIT is a paper-and-pencil measure of moral judgment development derived from Kohlberg’s theory.10 The test consists of six moral dilemmas that cannot be fairly resolved by applying existing norms, rules, or laws. Respondents rate and rank arguments (twelve for each dilemma) that they consider important in coming to a decision about what they would do if faced with that dilemma. The scores reflect the proportion of times that the respondent prefers each strategy: the PI (Personal Interest) Index reflects the proportion of times that he or she selects arguments that appeal to personal interests or loyalty to friends and family, even when doing so compromises the interest of persons outside one’s immediate circle; and the MN (Maintaining Norms) Index reflects the proportion of times that a respondent selects arguments that appeal to the maintenance of law and order, irrespective of whether applying the law to the dilemmas presented results in an injustice. The most widely used score, the P (Postconventional) Index, reflects the proportion of times that a respondent selects arguments that appeal to moral ideas. In addition to those three main indices, the N2 Index takes into account how well a person discriminates among the various arguments and has been found to be a better indicator of change than the P Index. If the N2 Index score is higher than the P Index score, it indicates that the respondent is better able to discriminate among arguments than to recognize postconventional arguments.
The validity of the DIT has been assessed in terms of seven criteria: differentiation of various age and education groups; longitudinal gains; correlation with cognitive capacity measures; sensitivity to moral education interventions; correlation with prosocial behaviors and professional decision making; correlation with political attitudes and choices; and adequate reliability (the Cronbach alpha value is in the upper 0.70s to low 0.80s; the test-retest reliability of the DIT is stable). Furthermore, the DIT shows discriminant validity from verbal ability/general intelligence and from conservative-liberal political attitudes.49
Moral motivation and commitment
The PROI consists of four ten-item rating scales that assess commitment to prioritize professional values over personal values.31 Items are created to reflect four dimensions (authority, responsibility, agency, and autonomy) that are theoretically linked to models of professionalism (commercial, guild, agent, and service) described in the professional ethics literature. The test-retest reliability for the items is 0.75, with a range of 0.68 to 0.82 for the four scales; the internal consistency is 0.54 for authority, 0.54 for responsibility, 0.58 for autonomy, and 0.69 for agency. The PROI scales—in particular, the responsibility and authority scales—have been shown to consistently differentiate beginning and advanced student groups and practitioner groups, who are expected to differ in their role concepts.31 Moreover, moral motivation as measured by the PROI has been found to improve with instruction.36 In addition, one study concluded that the authority and responsibility scales appeared to be core dimensions of four models of professionalism.50 Therefore, in our study, data analysis was performed on the authority and responsibility scales only.
Moral implementation
Scores assigned for a course in professional problem-solving were selected to serve as a profession-specific proxy measure for component four, moral implementation. Individual students had the opportunity to implement action plans for eight complex cases that present difficult human interaction problems. Each problem is representative of a class of challenging problems that arise in dental practice (e.g., interacting with a colleague whose patient case failed to meet standards or intervening in a case of suspected abuse or neglect). Students are required to plan strategies for handling the case, try out their dialogue on a peer, and submit a case write-up that includes an interpretation of the facts that must be addressed if the problem is to be resolved efficiently, an action plan, and a verbal dialogue to illustrate implementation of the action plan. A checklist, prepared for each case, ensures uniformity in judging responses. All responses are scored by the course director. Students have a chance to challenge their scores and to revise their responses based on the written feedback they receive. They also have the opportunity to submit a revised response to raise their grade on the exercise. Although the relationship between these scores and long-term competence has not been established, these performance-based assessments have face validity, similar to an OSCE, in that they reflect what the individual is able to do in a hypothetical clinical setting. Scores (ranging from 0 to 32) are tallied for each student at the end of the fourth year. The total score assigned represents eight judgments (0 to 4 points each) made about an individual student’s ability to implement action plans for the eight cases.
Procedure and Analysis
This study used existing archival data maintained by the dental school for twenty-five cohorts of students who completed an ethics curriculum and a set of outcome measures from 1982 to 2007. Following approval by the University of Minnesota’s Institutional Review Board (IRB), data for twelve males and twelve females were randomly selected from each cohort group for the graduating classes of 1996 to 2000. Before one of the authors and another graduate student were given access to any of the student responses on the DEST38 or to related scores on the other measures (test scores on the DIT,10 the PROI,31 and the PPS), all personal identification was removed. Identification numbers were assigned that blinded the authors and the other graduate student to the gender and identity of each student.
Before scoring the study sample, the first author and a graduate student colleague scored several DEST transcripts38 together and discussed each difference in scoring with the DEST developer. After developing a good understanding of all the criteria in the DEST scoring manual, the two raters scored several DEST transcripts independently and again discussed any differences in scoring with the DEST developer. For the data set in the study, the two raters then scored the same sixteen DEST transcripts independently and checked for reliability (0.92) before the first author scored the remaining 104 DESTs. The transcripts ranged from eight to twelve single-spaced pages of text.
Because Rest argues that the four components of morality are independent of one another, we did not employ a MANOVA, which assumes the measures are related to one another. To answer the first research question—is there gender difference on students’ moral sensitivity scores?—the independent samples t-test was performed on the DEST total scores. To answer the second research question—is there gender difference on students’ moral reasoning scores?—the mixed-design ANOVA, with gender as the between-subjects factor and time as the within-subjects factor, was used to analyze the DIT schema and N2 scores. Given that the DIT Type Indicator is an ordinal scale, a nonparametric Mann-Whitney U test was performed on this third measurement regarding this question. To answer the third research question—is there gender difference on students’ moral motivation scores?—the mixed-design ANOVA, with gender as the between-subjects factor and time as the within-subjects factor, was used to analyze the PROI authority and responsibility scores. To answer the last research question—is there gender difference in students’ moral implementation?—the independent samples t-test was conducted on the PPS scores.
Results
Moral Sensitivity
Table 3 shows the DEST means and standard deviations for students in the study by gender. An independent samples t-test was used to analyze the data. No statistically significant gender difference was found in the students’ DEST total scores or subtotal scores for each scenario.
Means and standard deviations for students’ Dental Ethical Sensitivity Test (DEST) responses in four scenarios, by gender
Moral Reasoning
Table 4 shows the pre- and posttest means and standard deviations for the students’ DIT schema scores (Personal Interest [PI], Maintaining Norms [MN], and Postconventional [P]), and for the N2 summary score. A mixed-design ANOVA, with gender as the between-subjects factor and time as the within-subjects factor, was used to analyze the data. No statistically significant gender difference was found for the students’ pretest or posttest DIT schema scores or summary score. However, a significant effect for time indicated that, except for the MN scores, both the men’s and women’s scores were significantly different at posttest.
Means and standard deviations for students’ Defining Issues Test (DIT) schema scores and summary scores, by gender
Table 5 shows the mean difference between pretest and posttest scores and the effect size for each of the statistically significant differences. As expected with an educational intervention, both men and women decreased their PI schema scores from pretest to posttest and increased their P scores and N2 summary scores. Effect sizes for the P and N2 scores ranged from 0.42 to 0.61. These effect sizes are consistent, with an average effect size of 0.41 (with a 95 percent confidence interval ranging from 0.28 to 0.56) reported for a meta-analysis of twenty-three intervention studies.51 In the meta-analysis, assessments of change for control or comparison groups were estimated at near 0, a finding that is consistent with analysis of change scores observed in professional education programs that do not have an ethics curriculum.24
Mean posttest-pretest difference and effect size by gender for students’ Defining Issues Test (DIT) schema scores and summary scores
Since DIT Type is an ordinal indicator of a student’s DIT profile, the nonparametric Mann-Whitney U test was used to analyze the data. A statistically significant gender difference was found in both students’ pretest DIT Type Indicator (p=0.04) and their posttest DIT Type Indicator (p=0.03). As shown in Figure 2, more women than men had a consolidated Type 7 profile at both pretest and posttest, and fewer women (21.7 percent) retained a consolidated Type 4 profile or maintained a transitional status.
Percentage of females and males at pretest and posttest for Defining Issues Test (DIT) type
Note: See Figure 1 for definition of types.
Moral Motivation
Table 6 shows means and standard deviations for the students’ PROI authority and responsibility subscale scores. A mixed-design ANOVA, with gender as the between-subjects factor and time as the within-subjects factor, was used to analyze the data. No statistically significant gender difference was found in the students’ pretest or posttest authority scale scores. However, a significant effect for time indicates that both men’s and women’s scores were significantly higher at posttest (Table 7). A statistically significant gender difference (favoring women) was attributed to differences in their posttest responsibility scale scores (F[1,118]=10.29, p=0.002). A significant time by gender interaction indicates that both men’s and women’s scores were significantly higher at posttest, but an effect size of 0.75 for women versus 0.5 for men indicates greater change for the women.
Means and standard deviations for students’ Professional Role Orientation Inventory (PROI) subscale scores, by gender
Mean posttest-pretest difference and effect size for students’ Professional Role Orientation Inventory (PROI) subscale scores, by gender
Moral Implementation
Table 8 shows means and standard deviations for the students’ PPS scores. The independent samples t-test indicates a statistically significant gender difference (t[118]=2.795, p=0.006, d=0.51) favoring women. An effect size of 0.51 suggests a substantial difference favoring women.
Means and standard deviations for standardized Professional Problem Solving (PPS) (Z scores), by gender
In summary, gender difference was not apparent for the measure of moral sensitivity but was evident for the type index of moral reasoning, for the responsibility dimension of moral motivation, and for the measure of moral implementation. Specifically, for the responsibility dimension of moral motivation, an effect size of 0.75 for women versus 0.5 for men indicates greater change for women. For the measure of moral implementation, an effect size of 0.57 suggests that the women’s ability to implement more effective action plans is not a trivial difference.
Discussion
Women have been increasingly entering the dental profession since the 1970s. To support the early recruitment of women, some argued that their presence—in what was historically a male-dominated profession—would bring an “ethic of care” to the profession. In fact, some studies reported a small, but statistically significant, gender difference favoring women on various measures of ethical competence: on measures of moral sensitivity,26,37,39 reasoning,11,24 and moral motivation.32 Our study examined whether male and female students who had participated in a four-year dental ethics curriculum and completed various well-validated measures of their ethical capacities differed on measures of moral sensitivity, moral reasoning, moral motivation, and moral implementation.
No statistically significant gender difference was evident on either the DEST total or any of the four story (subtotal) scores. This result differs from findings in a recent meta-analysis of ethical sensitivity studies43 and in an early study37 showing significant gender difference favoring women on the DEST, the same measure used in our study. One possible explanation might be the gender ratio change over the years: the ratio of men to women was 3 to 1 in the 1980s versus 1.8 to 1 in the current sample. Unlike the participants in the earlier study,37 who were admitted to dental school between 1979 and 1982, the current study’s female participants (admitted between 1992 and 1996) may be more similar to their male colleagues. In the last two decades, there has been a significant increase both in the number of applicants to dental school and in the proportion of female to male applicants. With increases in the number of applicants and the proportion of women accepted, greater equity in access to the dental profession may have been achieved.
Whereas small but statistically significant gender differences favoring women are typical in DIT studies, especially for the DIT P score, a statistically significant gender difference was evident only on our participants’ DIT Type Indicator. Specifically, more women than men clustered at Type 7 (predominant on the postconventional schema and consolidated), while more men than women clustered at Type 4 (predominant on the maintaining norms schema and consolidated). This pattern of differences was evident at both pretest and posttest and does not appear to be differentially influenced by the dental ethics curriculum. Whereas statistically significant change from pretest to posttest was evident for both men and women, suggesting that both benefited from the curriculum, there was no indication of a time by gender interaction to suggest that women benefited from the curriculum more than men. In fact, both men and women showed a statistically significant increase in their preference for arguments that appeal to moral ideals (the DIT P score) and a statistically significant decrease in their preference for arguments that appeal to personal interests (the DIT PI score). It is simply the case that 78.3 percent of the women were consolidated at Type 7 at posttest compared with 55 percent at pretest. For men, 61.7 percent were consolidated at Type 7 at posttest compared with 41.7 percent at pretest.
A statistically significant gender difference was evident in these students’ PROI responsibility scores. Specifically, women gave higher ratings than their male colleagues to a set of items eliciting their views about the breadth of their commitment to serve others (e.g., to patients who cannot pay for my services, to colleagues whose competence may be questionable, to third-party payers). Changes on both the PROI and the DIT support the notions that students’ conception of their responsibility changes over the four years of the curriculum and that the change is measurable. Findings from this study suggest that the change in perceptions of responsibility toward others may be greater for women than for their male colleagues.
A gender difference was not anticipated for the performance-based assessments (PPS scores) completed by students during the last two years of the curriculum. However, a statistically significant gender difference was evident in these students’ PPS scores, and the difference between women and men, measured in terms of effect size (d=0.51, women scored higher than men), was not trivial. The eight cases to which students responded required them to demonstrate their ability to design action plans and to create effective dialogues for ethical problems dentists are likely to encounter in their practice. After the case responses were submitted, students received written feedback on each, had an opportunity to revise their plans and dialogues, and resubmitted them, with the potential for an improved grade on each assignment. Although all students who received an unacceptable score on their first effort were required to revise and resubmit for an improved grade, this study did not examine the proportion or gender of students who took advantage of this opportunity.
Since a gender difference was not anticipated in the PPS scores, possible explanations for the observed difference (favoring women) must be examined. First, when the assignments were scored, the instructor who scored them was not blind to respondents’ gender. Second, the instructor was female. Male students may expend less effort on assignments required in a course that is directed by a female faculty member. The simple fact that women faculty members are in the minority in dental schools may itself perpetuate subtle biases that influence the environment for teaching and learning and the amount of effort expended by male and female students.
Countering the possibility that gender bias influenced either the scoring of responses on the part of the instructor or differential effort expended by male and female students are two points: a greater proportion of female students (78.3 percent) than male students (61.7 percent) demonstrated a consolidated Type 7 moral schema, and women demonstrated a greater sense of responsibility toward others as indicated by their higher scores on the responsibility dimension of the PROI.10 These two findings suggest that moral ideals and principals are likely to guide decision making, which, in turn, would influence the probability of moral action and the probability that women work harder (based upon greater moral motivation and commitment) to implement an effective plan of action. In addition, one study found that the small positive relationship between the DIT and intermediate concepts increases greatly when a developmental phase is included in the analysis.31 In other words, based on the type indicator, the consolidated status was associated with higher DIT P scores. Future studies should explore these potential explanations, just as the current study explored the reliability of gender difference initially observed on a measure of moral sensitivity.
Limitations and Implications
This study examined a group of dental students’ gender difference on measures of moral sensitivity, moral reasoning, moral motivation, and moral implementation. Some limitations must be kept in mind concerning the methods and results reported here since gender bias either on the part of the rater who scored the measure of component four processes or on the part of students who completed the component four responses may have influenced performance on the measure of component four (moral implementation).
With regard to future research, since Kang’s work on validation of the revised autonomy and agency scales of the PROI48 and archived PROI data are available for at least fifteen cohorts, future studies could examine gender difference using a larger sample as well as examining gender difference on the revised PROI autonomy and agency scales. Also, since archived data are available on PPS scores—the measure of component four—it would be possible to test the reliability of the gender difference observed for moral implementation in other cohorts who have completed the dental ethics curriculum.
There is some evidence that patients’ preconceived gender-based expectations and assumptions may influence rapport and communication between dentist and patient.19 Patients may perceive that women are more caring and therefore interact with them more effectively. Our study of moral sensitivity does not suggest that this sample of male and female students differed in their ability to recognize ethical issues—though of course there were individual differences among both men and women in their ability to recognize such issues. Of interest in this study was the greater facility the women demonstrated when asked to develop interpersonal dialogues and action plans to effectively resolve the eight moral conflicts they faced in the scenarios. Although these men and women did not differ when entering dental school in their moral reasoning or moral motivation as measured by the PROI responsibility scale, they did differ at posttest. The women expressed a greater responsibility toward others than their male colleagues, and, overall, they developed more effective plans of action. This finding suggests that educators may need to consider whether their ethics education programs are equally effective for facilitating each of the components of morality for male and female students.
Conclusions
This study extends previous research on the role of gender in morality using a comprehensive view of moral functioning. It has significance for the field of moral psychology and for dental and other professional education. Whereas previous research had explored gender difference almost exclusively with respect to moral cognition, data from a long-term curriculum project enabled exploration of gender difference in four capacities thought to be necessary conditions for moral behavior: moral sensitivity, moral reasoning, moral motivation, and moral implementation. Because pretest data were available for measures of moral reasoning and moral motivation, it was possible to show that men and women did not differ significantly at entry to dental school on two measures, but differential change was apparent at the end of the educational program.
Specifically, the women in this study did not differ from their male colleagues at the end of the third year on the ability to interpret the moral dimensions of professional problems, the first capacity in Rest’s FCM. Similarly, they did not differ significantly on moral judgment schema scores as measured by the DIT at either the beginning or end of the program. However, at both times of testing, differences were apparent in the proportion of women who demonstrated a moral judgment profile that was consolidated on the postconventional moral arguments (component two), suggesting greater certainty that moral ideals ought to be applied to resolve complex moral problems. Consistent with the perspective of developmental psychologists who argue that moral understanding leads to enhanced moral motivation and commitment (component three), which, in turn, would be reflected in the development of effective moral action (component four), the women in this study demonstrated a greater sense of responsibility to others at the end of the program. This attitude, in turn, was reflected in their ability to develop more effective plans of action to resolve complex ethical problems that arise in dental practice. Although the women in the study showed greater gains in moral motivation and a more consolidated moral judgment profile, both men and women enhanced their reasoning and motivation during the four-year dental ethics program.
REFERENCES
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