All one has to do is read the American Dental Association's Principles of Ethics and Code of Professional Conduct1 to realize that the profession of dentistry has a strong commitment to ethical behavior. Every member of the dental profession is expected to make a conscious commitment to abide by this code and its ethical standards. It is believed that by doing so, we will retain the trust of society, thereby helping assure that we preserve our ability to govern ourselves.
The Commission on Dental Accreditation of the American Dental Association2 requires every dental school to provide ethics education to their students to assure that the groundwork for ethical behavior is founded during dental school and carried into practice. Evidence suggests that the number of dental schools addressing issues related to ethics and professional conduct at the beginning of a student's academic experience has increased over the last two decades. But has it been enough or too little too late? Breaches of academic integrity in several well-respected dental schools in the United Sates have recently surfaced in news reports and reinforce the need for an even stronger ethics curriculum. Dental schools feel the commitment to convey the seriousness of ethical violations in the classroom, and if we cannot, how can we be confident that our graduates will demonstrate integrity as they practice dentistry? Assessing our effectiveness in this regard remains a challenge, because it is difficult to evaluate and/or track the ethical behavior of our dental graduates. It is even more difficult to determine the degree to which ethical behavior is associated with a student's experience while attending dental school. In 1998, a survey of dental schools showed that 86% of the schools surveyed reported having one or more reported/investigated case of academic dishonesty.3 This was a very disturbing survey, and it challenges us to question the effectiveness of our ability to teach ethics in the dental curriculum. Most certainly, all dental curriculums provide students with information about ethical conduct and their responsibilities as professionals to abide by that conduct, but it would appear that what is being taught and what is being practiced, by at least some of our students, are two different issues. Hafferty and Franks4 emphasize the distinction between ethics education and ethical conduct. Teaching dental ethics education cannot guarantee ethical dentists. It is my feeling that a dental school curriculum can just as easily create a need for students to become unethical if we are not careful. A curriculum that is numerically driven as a means of achieving clinical competency for graduation for its students runs the risk of its patients being perceived as points or procedures and having students make ethical choices about treatment based upon deadlines and graduation requirements rather than patient needs. Thus, the very ethical values we attempt to impart as academicians may be undermined by the educational approaches we endorse. So, what can be done? I believe we need to address two issues. The first involves a real need to look at how we are teaching ethics, and the second is the way we run our clinical programs. While many dental schools have one or two classes in ethics in their curriculums, few I believe have a true vision for what is needed to help instill the value of ethical behavior and the unconditional need for ethics in our profession. Most would ask: “Is ethics something that can be taught to a 23-year-old”? That is a good question that remains unanswered. A better question might be: “What measures can we take to help inspire proper ethical behavior in a three or four year curriculum?” My guess is that 23-year-old individuals already have a value system, so instead of thinking we can infuse proper ethical behavior in these individuals, we need to ask whether it is possible to modify their existing values. This is another good question, and may be one that does not have a very definitive answer. Regardless of whether behavior can be modified, I feel it is a mandate that as academicians we have an obligation to try. The first step in doing so is to create a curriculum which embraces ethical behavior. It must be incorporated into all years of the curriculum and throughout the majority of our dental courses, instead of being based on stand alone courses in ethics. I believe ethics should be tied to clinical cases and done in small group settings when possible, taking into account the constraints dental schools now face with diminished faculty numbers and lack of adequate classroom space. Ethical conduct must be a high priority for all faculty and staff and must be addressed frequently by upper administration. The message of its importance must be delivered on day one by the Dean. All faculty members must be role models who exemplify ethical character and demonstrate it at all times. The clinical curriculum must not be based on numbers of procedures but rather on proper delivery of patient care from day one. Thought needs to be given to preventing road blocks to students learning or patient care, thereby eliminating the need for students to creatively seek ways to circumvent the system. The days of the “Ivory Tower” approach to teaching must come to an end. A more realistic approach to learning must be found, based on what these student doctors will be faced with when they enter private practice.
There is no guarantee that graduates will be or will remain ethical, but continuing education on a yearly basis may help keep the vision of ethical care fresh in everyone's mind. Now is not the time to shy away from our responsibility as practitioners or as educators to assure that we all do our very best to demonstrate the need for ethics in our profession. We must believe that a better tomorrow begins today.
Russell O. Gilpatrick, D.D.S.
Dean, University of Tennessee
College of Dentistry
Memphis, Tennessee
References
1. American Dental Association: Principles of ethics and code of professional conduct. Chicago: American Dental Association, 2000.
2. Commission on Dental Accreditation: Accreditation standards for dental education programs. Chicago: American Dental Association. J Dent Edu 65(8): 1998.
3. Beemsterboer PL, Odom JG, Pate TD, Haden NK: Issues of academic integrity in U.S. dental schools. J Dent Educ 2000; 64:833-846.
4. Hafferty FW, Franks R: The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med 1994; 69:861-871.
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