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Teaching Ethics And Professionalism To Dental Students
by: Shelli Karp, BSc, DDS

As an instructor at the Faculty of Dentistry, University of Toronto, determining the best ways to teach ethics and professionalism to first year dental students can be very challenging. An underlying issue is whether or not teaching ethics to dental students can positively influence their ethical conduct as dentists.

Dentistry, like many other professions, has multiple "Codes of Ethics" for its members to follow. We talk of ethical behaviour and read about ethical misconduct, but what exactly are ethics? Are they innate? Can they be learned? Are they a choice? Are they a habit? Is there any value including it in the dental school curriculum or is it too late to teach ethics to dental students once they have been admitted into dental school?

Ethics is the study of what is right and wrong. It is the process involved in determining the most morally desirable course of action when confronted with a situation where a decision is required.

Ethics and professionalism are important parts of our practice of dentistry and need to be addressed. Ethics courses in dental school, articles in leading dental journals, advice columns in our governing boards' bulletins and continuing education courses, all contribute to laying the groundwork for our ethical behaviour and decision making process throughout our careers.

Is ethical behaviour innate?

Ethical behaviour may, to some extent, be innate. Just as our intelligence and personality has a genetic component, so may the characteristics that make some people choose to act ethically or unethically. According to Immanuel Kant (1724-1804) "what guides our willingness to adhere to rules is an innate, absolute moral sense; an inescapable feeling that something is either right or wrong."1 Some individuals seem to have this innate sense, which may be a more reliable means of distinguishing between right and wrong rather than relying on any written "Code of Ethics".

What Influences Whether A Person Acts Ethically Or Not?

Many factors influence one's ethical behaviour. Some of these are: parental and family values, religious and cultural background, important figures in one's upbringing, schooling and education, peers and colleagues, and the media. Everyone's collection of past experiences contributes to their own ethical reflection, a strong driving force in how they make ethical decisions.

For dentists, there are additional factors influencing one's ethical behaviour beginning in dental school and upon entering practice. Role models, who are people we look up to, having qualities we wish to attain, are a strong influencing factor of professional values, attitudes and behaviours for dental students. Compassion, integrity, and good relationships with their patients were attributes most valued in role models.2

Fear of failure, greed and envy may trigger one to act unethically. The stresses and pressures of dental school and private practice may affect just how strong the temptation is to act in an unethical way. For dentists, the influence of their peers and their own ability to justify their behaviour can affect their actions.

Although punishment is a strong deterrent to unethical behaviour it alone does not instil ethical beliefs or behaviour, as people are often tempted to find a way to avoid trouble as a substitute for true ethics. But if we do not stress the seriousness of ethical violations in dental school, then how can we be confident that our graduates will demonstrate integrity in the practice of dentistry?3 "At least one study has shown a relationship between dental school behaviour and that in private practice, suggesting that the issue certainly needs to be addressed."4

Can we teach dental students to act ethically?

By the time well-educated, high achiever students get into dentistry, you might think that they should know the difference between right and wrong. But if they have gone through their entire life cheating, lying or acting unethically, can they really be taught to act ethically, now? Most likely, one who is not interested in being ethical also is uninterested in the reasons why one should act ethically. Knowing dental ethics and being ethical are two different things; an individual has to know better in order to act better. But is knowing better enough? Acting unethically is not necessarily because one does not know what is right; it is much deeper than that.

Dr. Charles Bertolami strongly feels that while ethics courses do succeed in telling students what our expectations are of them, they do not address the questions everyone really wants the answer to: Why be good? Why be ethical?5 He argues in favour of "enlightened" self interest, a philosophy in ethics which states that persons who act to further the interests of others, ultimately serve their own self-interest. It has often been simply expressed by the belief that an individual, group, or even a commercial entity will "do well by doing good."6 Dr. Bertolami stresses the necessity of introspection of one's own true feelings, beliefs and long term interests, for ethical behaviour to follow.

Ozar and Sokol also stress such introspection as a means to being ethical. They state that "Most people do not ordinarily choose to become ethical or continue being ethical when it is a difficult situation that involves sacrifice and risk, simply because someone has offered them a carefully reasoned argument about being ethical. They do so from even more complex reflections about the sort of person they want to be, the qualities of the persons in their lives whom they have come in contact with and admire, the communities with which they want to be identified, and the efficacy of various courses of action and patterns of life in relation to these matters."7

Although, ideally dental students should act ethically due to a deeper "introspective" and "reflective" personal philosophy, dental school faculty have a key role to play in guiding and positively influencing students in further developing professional dental ethics. Having our dental students see that ethical behaviour is in their own self interest; that having a good relationship with one's patients, where the patients feel comfortable and trusting of their dentist can be a material benefit to the dentist, in that satisfied, contented patients will happily refer new patients to one's practice, may be beneficial.

Is there value in taking the time in the curriculum to teach ethics?

Not only is there value in teaching ethics, it is a must. To get a driver's licence you must first pass a test setting out the "Rules of the Road." Similarly, before graduating and being licensed to practice dentistry, it is necessary for dental students to learn and be tested on the technical aspects of procedures they can perform and to be informed about professional codes of conduct, also known as a "Code of Ethics."8 How codes of conduct are learned can be problematic. Deinhart (1995) criticizes ethical codes. "First, he argues that codes cannot and do not alter behaviour. This is because as Ladd (1985) notes, "Those to whom it (a code) is addressed and who need it most will not adhere to it anyways, and the rest of the good people in the profession will not need it because they already know what they ought to do."9

How should ethics be taught to dental students?

Teaching ethics must not be isolated to just teaching the written code solely by classroom lectures which do not engage the students and invite their active participation. A dental student's ethical behaviour could more likely be affected by being taught a course on ethics that includes both didactic learning of the code of ethics and "hands on" discussion of ethical dilemmas and scenarios breathing life into the real values at stake. Smaller discussion groups can be a more interesting and effective way of teaching ethics. By giving students examples of ethical scenarios based on true patient cases or composite case studies and having students involved in resolving them increases the likelihood that they will not only learn about ethical conduct but more importantly apply what they have learned when a real situation arises in their practice life. This helps give them the awareness and skills needed to work through the ethical decision making process step-by-step.

Based on the author's experience as a part-time instructor at the Faculty of Dentistry, University of Toronto undergraduate dental program, role playing, story telling and group discussions are effective ways to approach and teach this subject. Talking in small groups about ethical decisions gives students the opportunity to think, hear other people's views and beliefs, voice their own opinions and defend their point-of view, and learn and reflect on what is important to be a "good" person and ethical dentist. The debate on how they would handle different situations compels students to examine their own values and beliefs. By listening to other students' opinions they realize there can be more than one solution to an ethical problem. These alternative solutions are often very different from their own.

Ethics courses should give students the moral courage they need to make the right choices when they already know right from wrong. Stressing the values and ideals that individual dentists and the dental community as a whole are committed to as professionals can contribute to the individual student's ongoing reflection on how to be a good person and dentist, the sort of professional he or she should strive to be. Values become stronger and more consistent when they are personalized and internalized by way of reflection rather than just mimicking the behaviours of others. This happens by observation, critical thinking, questioning and wrestling with dilemmas and addressing the pressures of dental education and practice.

Can good ethical behaviour become a habit?

Emile Durkheim says that "habits are the real forces which govern us.... and as they acquire force; they are transformed into rules of conduct."10

Ozar and Sokol state: "...most of the actions we perform in life are not the product of careful, self-conscious deliberations about our alternatives. Most of the actions are, as we might say, "just done." That is, they are done without careful reflection at the time. But this does not mean that most of our actions are irrational. Rather, they are done from habit. Probably 95 per cent or more of our actions are the product of various habits of acting, perceiving, valuing and so on..... The reason that these actions, though they are not carefully reflected upon at the time, cannot be simply described as irrational, is that the habits these actions come from are, for the most part, available from careful reflection and subject to thoughtful choice."11 What this means is..... we judge a situation, and then we choose which particular habit we want to act on, resulting in our actions. One might say that it is pointless to study ethics if our actions are just the products of habits with no thought process. But we are the ones with the ability to judge and choose our habits. By discussing many different cases with students, they can examine and reshape their habits that will help them to act ethically in situations they are called upon.

Conclusion

There are many pre-existing factors inf luencing our dental students before they enter dental school, and it may well be that their ethical behaviour is quite established by that time. Our present admissions system takes this into consideration with a personality test and ethically related interview questions. With strong competition to get into dental school, it is reasonable to conclude that students accepted into dental school are well prepared and quite aware of the "correct" answers they should give on these tests and interview questions.

From my observations as an instructor teaching seminars on ethics and professionalism to first year students at the Faculty of Dentistry, University of Toronto, I have a favourable impression of their general ethical attitudes as they enter dental school.

I have asked these students whether or not we can teach good ethical behaviour and whether it is useful and valuable in the curriculum. The results were very intriguing. Many students felt that getting into dentistry was an opportunity and the right time to turn over a new leaf and the perfect time to put their past behind them and move forward in a professional and ethical way. It was time to live up to the obligations and responsibilities that are an integral part of being a professional as they embark on their journey to becoming practising dentists.

My sense is that most students indeed do have a pre-existing generic concept on what ethical conduct is and the notion that there is a difference between right and wrong. Furthermore, at this early stage, students are most receptive to learning appropriate ethical behaviour related to the practice of dentistry. However, it remains to be seen what the effect of the intrinsic competitive nature of students getting accepted into dental school, the competition to achieve high grades to get accepted into post-graduate programs, the high personal cost of attending dental school and the significant debts facing graduating dental students, among other things, will have on the ethical values and behaviour these same students will take with them upon leaving the dental school after graduation. This is truly a daunting responsibility for instructors at the Faculty and in fact, for all members of the dental profession. It is definitely an exciting challenge to teach ethics and professionalism to dental students.

In answer to the question, is it too late for dental students to learn ethics after entering dental school, my resounding answer is "definitely not." The transition period from being "just" a student to being a student in a healthcare profession in the Faculty of Dentistry is truly the best and most important time for shaping their moral views that will affect the ethical choices in their clinical practice both in dental school and thereafter. It is significant to hear dental students say that the 'White Coat Ceremony' which all students experience in first year affirming their obligations as dental students was a valuable and significant experience in their life. Many have framed their 'Oath of Commitment' and hang it up as a constant reminder of their responsibilities as dental students and an important symbol of what the profession expects of them. A suggestion has been made to perhaps repeat the White Coat Ceremony again in fourth year to re-emphasize these principles upon graduation. Courses teaching ethics and professionalism starting in first year and reinforced often throughout their attendance at the dental school support and inspire excellent ethical behaviour and strengthen self-reflection and moral reasoning. These are essential for the well being of individual students, the dental profession as a whole and the patients we serve.

Dental school curriculum must stress to our students the importance of defining values and learning ethical habits that reflect integrity and good moral behaviour. Is the basis for the Code of Ethics any different from the values that each of us learned from our parents? The Golden Rule, 'treat others as you want to be treated', be honest, don't steal, cheat or lie are fundamental to and the basis for ethical and professional conduct. Ultimately it is the person's own choice to follow what they have been taught, choose to be ethical and to value ethical decision making.

It seems that the first year of dental school is the ideal time for ethical reflection and insight and guiding dental students on how to make the appropriate choices which will shape and affect their dental school, professional and personal lives in the future. Students seem to prefer and better learn about ethical values by means of scenarios, role playing, case studies rather than purely lectures. Students must first recognize that they have an ethical dilemma, whether in the class, the lab or in the clinic, and then use what they have learned in their decision making process.

It goes without saying that to support the teaching of ethics, instructors and the Faculty must model appropriate behaviour. The old sayings, "lead by example" and "practice what you preach" are as applicable now as always. The Faculty and student body should strive for zero tolerance for unethical behaviour and enforcement consistent with the seriousness of the infraction. Students must gain the motivation to resist the temptations to breach ethical standards for selfish gain. The emphasis should be on showing how being ethical can in fact further their own self interest.

It is debatable whether the stress and pressure imposed on dental students in order to learn how to become an excellent dentist can be eliminated. However, efforts to reduce the pressure and demands put on students to be the "best" dental student at the expense of ethical and moral values should be propagated and valued to foster appropriate "outcomes" which better reflect the type of balanced graduating dentist needed to treat patients ethically and professionally.

Whether ethics are innate, learned, by choice or habit is open to debate. However it should be widely agreed that regardless of how they are obtained, it is critically important that dental students (and dentists) should aspire to acquire the skills necessary to identify, develop and internalize appropriate morals which will lead to a more ethical profession and practice of dentistry. Being sensitive to the cultural diversity and differing backgrounds of the students comprising our new classes each year, may require revisions to how ethics and professionalism should be taught. Students vary in the way they learn and this should be reflected in the different methods used for teaching. Various methods of teaching were discussed in this article, such as lectures, role playing, scenarios, case studies and group discussions and they should continue to be used in teaching the curriculum.

With continued and effective teaching of ethics and professionalism at the dental school level and positive role models of the teaching faculty (and the profession at large), the moral and ethical consciousness of dental students can be raised to the highest levels possible. The future of dentistry is in the hands of our graduating dental students and providing them with a sound ethical and professional basis for practising dentistry is in the best interests of the students, dentists, the profession and the public we serve.

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Shelli A. Karp received her B. Sc. from Queen's University in 1978 and her DDS degree from the University of Toronto in 1982. She maintains a full time dental practice in Scarborough, ON. She is currently a part-time clinical instructor and demonstrator at the Faculty of Dentistry of the University of Toronto.

http://www.oralhealthjournal.com/issues/ISarticle.asp?aid=1000226351