SEJ_2-2017_Articol_Giusti
DENTAL ETHICS
ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
Original Articles
Lola K. Giusti1a*, Bruce Peltier1b, Lynn G. Beck Brallier2c, Tobias E. Rodriguez3d
1
Department of Dental Practice, Arthur A Dugoni School of Dentistry, University of the Pacific
155 Fifth Street, San Francisco, CA 94103, USA
2
Gladys Benerd School of Education, University of the Pacific
3601 Pacific Avenue, Stockton, CA, 95211, USA
3
Academy for Academic Leadership
3565 Piedmont Road, NE, Building One, Atlanta, GA 30305, USA
a
DDS, MA, FACD, FICD, Associate Professor
b
PhD, MBA, Professor
c
PhD, Professor and former Dean
d
PhD, Vice President
Received: January 11, 2017
Revised: February 16, 2017
Accepted: March 13, 2017
Published: March 14, 2017
Academic Editor: Sanda Mihaela Popescu, DDS, PhD, Professor and Head, Dental Reabilitation and Medical Surgery Emergencies Department,
Faculty of Dental Medicine, University of Medicine and Pharmacy of Craiova, Dolj, Romania
Cite this article:
Giusti LK, Peltier B, Brallier LGB, Rodriguez TE. Ethics instruction at California dental schools. Stoma Edu J. 2017;4(2):134-139.
ABSTRACT DOI: 10.25241/stomaeduj.2017.4(2).art.6
Purpose/ Objectives: This essay is a report of qualitative research conducted in 2015 to determine
the methods that California dental schools use to educate undergraduate dental students in
professional ethics. Its purpose was to describe Dental Ethics curricula in the State of California
and describe diverse undergraduate programs, foster communication and collaboration between
schools, and facilitate dialogue.
Methods: Faculty members identified as Dental Ethics Course Directors at four schools were
contacted by phone to inform them of the research project and invite participation. Subjects then
responded to an emailed survey questionnaire.
Results: Results were collated and analyzed.
Conclusions: Effective ethics instruction is an essential component of modern dental education, and
results show that each of the four schools uses a variety of methods to accomplish the task.
Keywords: dental education, dental ethics, professionalism education, Codes of Ethics, principle-
based ethics.
1. Introduction Sharp et al, foremost in the concerns of fourth year
Dental students come to their schools with students were the lack of resources on the part of
diverse foundations in ethics and ethical behavior. their patients.5 Students perceive such disparities
Most are influenced by their culture, families, as ethical issues. Indeed “students struggle with
educational backgrounds, life circumstances, and a sense of obligation to treat patients fairly and
socioeconomic levels. equally and are troubled when they are unable to
This study describes the ways in which four do so.” Other concerns reported by these students
California dental schools teach their students to involved conflict between clinicians in treatment
recognize ethical dilemmas in practice, analyze plans; practices or policies inconsistent with the
various courses of action in responding to them, standard of care; and identifying the appropriate
and prepare for ethical practice after graduation. surrogate decision maker, among others.
1.1. The Current Situation Seminal research in this area was conducted by
Dental faculty are charged with teaching ethics Lantz, Bebeau and Zarkowski, and published in
to young professionals who may not incorporate the Journal of Dental Education in October of
consistent ethical concepts into their daily 2011.12 The researchers queried faculty in Dental
interactions with faculty, staff and patients. Ethics courses at all fifty-six (at the time) dental
Academic and life stressors affect dental students schools with respect to the instructional methods
during their first year especially, and throughout and assessments used in these programs. In
dental school.1,2 Dental students may not perceive recommending future research in this area, the
the value of ethics courses, and they (as well as authors offered the following suggestion: “First, we
administrators) may believe that the subject is dry conclude that dental schools should use measures
and boring.3,4 Nonetheless, students have proven to assess the learning outcomes of their ethics
to be very concerned about ethical conundrums instruction. These outcome assessments not only
faced in their practice with patients. In a study by provide a way to ensure that schools are achieving
*Corresponding author:
Associate Professor Lola Giusti, DDS, MA, FACD, FICD
Department of Dental Practice, Arthur A. Dugoni School of Dentistry, University of the Pacific, 155 Fifth Street, San Francisco, CA 94103, USA
Tel: 415.351.7104; Fax: 415. 749.4338; e-mail: lgiusti@pacific.edu
134 Stoma Edu J. 2017;4(2): 134-139 http://www.stomaeduj.com
ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
desired learning outcomes, but also a mechanism Foundational exploration of this critical subject in
Original Articles
for documenting the ethical competence of dentistry was published in a two-part white paper
graduates and setting goals and charting progress by Professor Muriel Bebeau at the University of
toward improving learning outcomes.” This study Minnesota. The purpose of this publication was
seeks to continue inquiry into the various ways described as follows:8
Dental Ethics are taught in California schools. The “The goal is to help participants identify and
researchers asked leaders at four California schools address personal shortcomings that led to
questions regarding the individuals involved in disciplinary action, while simultaneously satisfying
teaching dental ethics in the predoctoral curricula. the board’s need to feel that they have fulfilled their
One of the first questions of interest is, “Who responsibility to the public.”
should teach ethics?” and by extension, “Whose Seminal work undertaken by Bebeau in Part Two
ethics should be taught?” Should the subject be of that analysis focused on the areas of ethical
taught by a dentist, a psychologist, or a trained sensitivity, moral reasoning, and role concept,
ethicist? Additionally, should the subject matter among others.9 It “examines the effectiveness
be presented in conjunction with discussions of the specially-designed ethics courses for the
of clinical-technical topics? The next questions 38 referred professionals who completed one
follow naturally: “How, when, and where should or more of the assessments following instruction
the subject be taught?” and, of course “How and summarizes their perceptions of the value
can we know if our curricula are effective? Do of the process.” The use of cases as well as
students behave differently as a result of our Ethics reflections and self-assessments enabled dentists
Education curricula? to “change their minds about prior beliefs and to
This study is part of a small but growing body of engage their colleagues in addressing issues of
research that has sought to understand both the professionalism.”
processes and structures (as well as the impact) Subsequent inquiry into the “essential role
of ethical education in medical, dental, and other of medical ethics education in achieving
professional schools. professionalism: The Romanell Report”
The need for ethics education during dental underscored the importance of ethics in
school has been clearly established. Accreditation improving patient care outcomes.10 The authors
standards for Dental Ethics and Professionalism analyzed ethics instruction, and assessments and
have been written and implemented. The interventions used in the field of medicine. They
Commission on Dental Accreditation (CODA)6 has seem to share the concerns expressed by Bebeau
set the following guidelines for predoctoral dental and others who teach dental ethics. Among their
education: 2-20. Graduates must be competent in conclusions are the following:
the application of the principles of ethical decision “However, our report also identifies many
making and professional responsibility. challenges facing medical ethics educators. First,
1.2. Intent there is no consensus about specific educational
Graduates should know how to draw on a range of objectives for medical ethics and professionalism.
resources, among which are professional codes, Second, several pedagogical methods have been
regulatory law, and ethical theories. These resources shown to offer some benefit to learners, but the
should pertain to the academic environment, supporting data are rarely robust, and educational
patient care, practice management, and research. approaches vary greatly between programs
They should guide judgment and action for issues and institutions. Third, increasing pressure to
that are complex, novel, ethically arguable, divisive, demonstrate effectiveness raises particular
or of public concern. challenges for faculty teaching medical ethics and
The structures and processes to provide this professionalism because these educational efforts
education continue to be of interest to dental do not always produce short-term, quantitatively
educators. Faculty teach and reinforce these measurable improvements. Finally, the “hidden
concepts at three levels: legal (arguably the curriculum” can undermine learners’ professional
minimum standard), risk management, and development, creating a need for attention to
ethical, or aspirational. At the legal level there is the learning environment and for widespread
content dedicated to regulatory practices, codes, faculty development that would require significant
and other subjects such as standard of care, and resources and expertise.”
these are often taught in free-standing Dental Law A recent study at the University of Iowa College
courses. Students are taught risk management of Dentistry proposed a model of the desired
throughout the curriculum in topics related to characteristics of a dental school graduate,
communication, documentation, and the use including ethical and professional values. The
of technology, among other curricular themes. proposed schema outlined three key values:
Teaching and reinforcing ethical-moral principles (1) dedication to care of patients, (2) empathy/
and the higher aspirations of the dental profession honesty/ integrity, and (3) self-respect and respect
provide ongoing challenges to educators. for the others. These values were identified as
Understanding the legal principles reinforced central among the desired characteristics of a
during dental education can be done graduate from the institution.11
retrospectively. By analyzing the sorts of problems Another question involves the impact of teaching
encountered by dentists in practice educators and learning in this content area: Do students
might work “backwards” to create course content. change their thinking as a result of ethics
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ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
instruction? A preliminary study carried out at the practices described below.
Original Articles the University of Istanbul indicates an affirmative
conclusion.13 Case scenarios were presented to 2. Methods
fourth year students (n=37) who were presented The Institutional Review Board approval was
with a four topics approach to clinical ethics obtained for the unfunded project, with expedited
(medical indication, patient preferences, quality of review. Faculty members identified as Dental Ethics
life, and contextual features), and asked to solve Course Directors at four California schools were
the case using their knowledge of ethics, which contacted by phone to enlist their participation
they had gathered from a lecture in their third year. in a qualitative study. After completion of the
Thereafter students received a three-hour lecture Informed Consent processes, faculty members
on the four topics approach, used for clinical ethical from four of the schools completed an electronic
case analysis. After completion of the lecture, the survey (see Appendix 1) and respondents
same case scenario was presented to the students attached relevant course documents. The survey
again. There was significant development in instrument was developed as a cooperative effort
the students’ performance after the course. The between a student in a Master’s program and
authors provide evidence that ethical decision- faculty members at the University of the Pacific
making can indeed be taught and learned within Benerd School of Education and the Academy
the framework of a dental school course. for Academic Leadership. Participation by the
This topic was also investigated by faculty in the schools was entirely voluntary. The participants
fields of business and accounting. Two studies responded to approximately ten questions via
published in the Journal of Business Ethics in electronic survey and attached relevant course
2015 demonstrate interest in the impact of ethics documents. Responses were collected and
education upon student behavior. The first study, analyzed qualitatively, with telephone follow-up
published by Martinov-Bennie and Mladenovic in those cases where data collection required
(2015), analyzed how accounting students develop it (clarification of responses by the principal
ethical sensitivity and ethical judgment. Their investigator).
findings indicate that the existence of a framework The work was undertaken as a pilot study to
alone does not appear to increase ethical sensitivity, promote collaboration and communication
but that an integrated ethics component using about best practices in dental ethics instruction at
case studies can increase ethical sensitivity. Ethical California dental schools.
judgment was similarly affected by the integrated
education program. The second study, done at 3. Findings/Results
West Chester University of Pennsylvania with All the schools utilized a lecture format to deliver
undergraduate business students, researched the content in Dental Ethics courses. Small group
roles of gender, personal ethical perspectives, and exercises were also used by these institutions.
moral judgment in business ethics instruction.14 Among the schools a variety of approaches to
The findings demonstrated there was variability learning activities are employed: group projects,
connected to the type of ethical dilemma, and some flipped classrooms (a teaching method that
effect linked to gender, but no main effect of each delivers course content outside the classroom)
factor. The authors discussed their conclusions with prep assignment, daily reflections, online
by stating (page 600), “Finally, we would like to materials, an American College of Dentists video
reiterate a concern of other researchers that the course (with completion certificate required),
way in which students respond to ethical dilemmas panel discussions and American Society of
in the classroom may not be indicative of how they Dental Ethics projects and readings. Students
will react to ethical challenges in the real world.” receive lectures on the CDA Code of Ethics and
For example, the analysis of whether or not the the Dental Practice Act. Other methods used for
ethics curricula are effective has been vigorously student engagement were lunch and learn, and
debated by Bertolami and Jenson.15,16 Spirited course electives focusing on professionalism and
analysis of academic dishonesty promoted ethics. Content was delivered at a variety of times
national discussion. In responding to Bertolami’s across doctoral programs, with courses specifically
assertion that students continue to cheat in spite designated as “Dental Ethics” or “Dental Ethics and
of the existence of dental ethics courses, Jenson Jurisprudence” at two of the schools. One school
maintained that (page 227): seeks to “demonstrate the highest quality of care,
“…dental ethics courses, as they are now taught, governed by ethical principles, integrity, honesty
are essential and valuable. Could they be better? and compassion.” It performs assessments in this
Absolutely. Could they actually provide students domain “through solving ethical dilemmas in
with the moral courage needed to make the right group discussions and applying principles in a
choices when they already know right from wrong? clinical setting.” It extends ethical discussions from
This is an open question and one that deserves the classroom to the clinical setting via efforts to
some empirical research.” “demonstrate collaboration with clients and with
The authors of this paper assert that ongoing other health professionals to develop a plan of
efforts to assess and improve ethics instruction in care to achieve patients’ positive health outcomes.”
dental education are essential. The dental schools Another institution has designed courses in ethics
that participated in this research respond to the specifically for orthodontic residents as well as
charge of educating ethical practitioners through international dental students. Faculty mentioned
136 Stoma Edu J. 2017;4(2): 134-139 http://www.stomaeduj.com
ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
that ethics was mentioned in the classroom and programs is in the midst of revision with its second
Original Articles
clinical scenarios across all years of their programs. and third year courses, all faculty reflect the spirit
For example, a Systems Based Healthcare course of collaboration in their curricula, with a range
presented opportunities for dental students in from “not much, some in the past,” to guided
their third year of training to interface with other collaborations with Schools of Medicine and
healthcare providers in a venue where “topics Nursing. Another institution anticipates classroom
include team building, conflict resolution, sexuality collaboration with students from its dental hygiene
and healthcare law, healthcare delivery and program. Faculty also derive inspiration from
reimbursement, quality improvement, economic ASDA through its materials and methods, and
and cultural considerations in healthcare decisions, course notes at meetings of the American College
and public and personal perspectives of what of Dentists. Course directors also employ online
constitutes conflict of interest.” Other areas in coursework for their own education in Ethics.
which learning sessions take place are lectures on In response to a query concerning ethical issues
topics such as “Ethical Issues in Research” nested faced by students, a number of topics surfaced.
within a “Critical Thinking and Lifelong Learning” One instructor felt that the “challenges are
class. Malpractice and misconduct issues are largely the same as the ones we faced years ago.
specifically discussed at all of the institutions. Small The big difference is that technology magnifies
group case discussions with written summaries the opportunities.” Others mentioned that the
are used, and oral summaries are given “as called competition for grades and patient needs vs.
upon in large group discussion.” One school clinical requirements factor into the challenges
invites a guest lecturer from the California Dental students manage during their education. “The
Board to speak to its students. Another presents majority of students are aware of what is right to
students with a panel discussion of California do, but a few make bad decisions when faced with
Dental Association member dentists who have a challenge that threatens their grades or ability to
struggled with alcohol and drug addiction issues in graduate on time.” One faculty member dedicated
conjunction with disciplinary actions by the Board. a book chapter to precisely this subject. Another
In addition, an attorney experienced in legal ethics stated that “there have been several JDE (Journal
regularly attends small group seminars, helping of Dental Education) articles on this topic that
to promote discussion in topics ranging from accurately identify ethical challenges in predoctoral
informed consent, documentation, and contracts dental clinic.” At one institution students are asked
to challenging clinical scenarios faced by students to reflect upon the notion that clinic requirements
in their patient care. serve as a proxy for money during their training,
Competence assessments in dental ethics are met on the premise that financial issues will arise after
in a number of ways. Course directors employ graduation. In terms of ethical challenges faced
multiple choice exams, written exams, reflection by students, another faculty member stated that
papers on ethical issues in clinic, case analysis, and “patient needs vs. clinical requirements is the big
a video project. Students also use a live theater one.”
presentation at one of the schools to demonstrate Faculty members also face challenges in teaching
their understanding. Other methods of assessment their courses. Two themes emerged from the
include periodic quizzes, dentalethics.org modules research: 1) Eliciting participation from mainstream
and discussions of classroom activities. faculty members, and 2) intrinsic lack of student
Because of the attempts of faculty across interest in the subject. “We need more time and
disciplines to include ethics instruction in their resources (trained faculty) to do smaller group
courses it can be difficult to estimate the number case based learning, especially…after students
of hours devoted to the subject in total. However, have had clinical experience.”
available estimates range from twenty to over forty Another mentioned that instructors are challenged
hours of dedicated clock hours to formal ethics by “carving out sufficient time to deliver content in
instruction at the schools surveyed. a very dense curriculum” and “keeping students
The professional backgrounds of the course engaged by balancing the philosophy with real
directors and faculty members charged with life situations.” Faculty members make a concerted
teaching the subject are varied. The group effort to actively engage students in their
of faculty at the schools includes a variety of assignments and classroom activities.
individuals: a hygienist with an Ed.D., experienced “Making it interesting and relevant, including
general dentists, psychologists, a general dentist enough clinical information for relevance without
with a Master’s degree in ethics, a dentist self- taking the focus off ethics. We focus on Ethical
taught in ethics, Associate Deans from Academic Moments common ethical dilemmas and introduce
Programs, Student Affairs, Clinical Dental Sciences, an ethical theoretical framework on how to reason
and the Student Clinic Director. Some of the faculty through a situation.”
members have formal ethics training and some do “Students are really busy and seem focused on
not. Several of the faculty members belong to the “clinical” courses; hard to get them to do the
American Society of Dental Ethics, while others are readings. There has been consistent support from
not members. administration and the number of hours has never
Collaboration with other departments or schools been cut or threatened.”
at the respective institutions occurs in a number of
ways to deliver course content. While one of the
Stomatology Edu Journal 137
ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
4. Conclusions resources to the endeavor. Future research will be
Original Articles This study looked into the methods used by four necessary to understand the best practices to carry
California dental schools to implement their ethics out this important educational component of training
curricula. While there appears to be unanimous undergraduate dental students.
concern that students are able to recognize moral
dilemmas in clinical practice, the schools employ a Acknowledgments
variety of measures to prepare their students for ethical The authors report no conflict of interest and there
practice. Institutions across the board take this charge was no external source of funding for the present
seriously, and dedicate time, curricular content, and study.
Appendix 1. Ethics Survey Questions
1. In what courses are Dental Ethics taught at your institution? When and how is competency in dental
ethics assessed in your curriculum?
2. What is the professional background of the course director and those that teach ethics?
3. Please describe, in as much detail as possible, the course content. Feel free to attach course syllabi to
this email if you wish. Please include learning objectives, themes, assessments, etc.
4. Are you aware of how other schools or departments collaborate with other dental schools in creating
or delivering course content in Dental Ethics?
5. How are students assessed in your Ethics course(s)? Check all that apply.
a. quiz
b. multiple choice exam
c. observation
d. video
e. paper
f. case analysis
6. What ethical challenges are students at your institution faced with? How aware are your students of
ethical challenges?
7. What are the challenges you face in teaching your course(s)z
8. May I contact you in the future to follow up on these questions? What is your preferred email address/
phone #?
References
1. Silverstein ST, Kritz-Silverstein D. A longitudinal study 10. Carrese JA, Malek J, Watson K, et al. The
of stress in first-year dental students. J Dent Educ. essential role of medical ethics education in
2010;74(8):836-848. achieving professionalism: the Romanell report.
[Full text links][Free Article] [PubMed] Google Acad Med. 2015;90(6):744-752. doi: 10.1097/
Scholar(64) Scopus(25) ACM.0000000000000715.
2. Crego A, Carrillo-Diaz M, Armfield JM, et al. Stress [Full text links] [PubMed] Google Scholar(38)
and academic performance in dental students: the Scopus(18)
role of coping strategies and examination-related self- 11. Schneider GB, Cunningham-Ford MA, Johnsen DC, et
efficacy. J Dent Educ. 2016;80(2):165-172. al. Outcomes mapping: a method for dental schools
[Full text links] [Free Article] [PubMed] Google to coordinate learning and assessment based on
Scholar(14) Scopus(9) desired characteristics of a graduate. J Dent Educ.
3. Sharp HM, Kuthy RA, Heller KE. Ethical dilemmas 2013;78(9):1268-1278.
reported by fourth-year dental students. J Dent Educ. [Full text links] [Free Article] [PubMed] Google
2005;69(10):1116-1122. Scholar(8) Scopus(3)
[Full text links] [Free Article] [PubMed] Google 12. Lantz MS, Bebeau MJ, Zarkowski P. The status of ethics
Scholar(47) Scopus(16) teaching and learning in U.S. dental schools. J Dent
4. Bertolami CN. Why our ethics curricula don’t work. J Educ. 2011;75(10):1295-1309.
Dent Educ. 2004;68(4):414-425. [Full text links] [Free Article] [PubMed] Google
[Full text links] [Free Article] [PubMed] Google Scholar(29) Scopus(12)
Scholar(129) Scopus(44) 13. Ilgüy M, Ilgüy D, Oktay I. Ethical decision making in
5. Sharp et al. p.1120. dental education: a preliminary study. BMC Med
6. ***Commission on Dental Accreditation: Accreditation Ethics. 2015;16:52. doi: 10.1186/s12910-015-0046-4.
Standards for Dental Education Programs. 2016. [Full text links][Free PMC Article] [PubMed] Google
[Internet: available www.ada.org/en/coda. http:// Scholar(3)Scopus(0)
www.ada.org/~/media/CODA/Files/predoc.ashx. Last 14. Wang LC, Calvano L. Is business ethics education
accessed 8th April 2017] effective? An analysis of gender, personal ethical
7. Bebeau MJ. Enhancing professionalism using ethics perspectives, and moral judgment. J Bus Ethics.
education as part of a dental licensure board’s 2015;126(4):591-602.
disciplinary action. Part 1. An evidence-based process. Google scholar(45) Scopus(13)
J Am Coll Dent. 2009;76(2):38-50. 15. Bertolami CN, Ibid.
[PubMed] Google Scholar(22) Scopus(14) 16. Jenson LE. Why our ethics curricula do work. J Dent
8. Bebeau MJ, p.38. Educ. 2005;69(2):225-228; discussion 229-231.
9. Bebeau MJ. Enhancing professionalism using ethics [Full text links] [Free Article] [PubMed] Google
education as part of a dental licensure board’s Scholar(22) Scopus(5)
disciplinary action. Part 2. Evidence of the process. J
Am Coll Dent. 2009;76(3):32-45.
[PubMed] Google Scholar(24) Scopus(15)
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ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
Original Articles
Lola GIUSTI
DDS, MA, FACD, FICD, Associate Professor
Department of Dental Practice
Arthur A. Dugoni School of Dentistry
University of the Pacific
155 Fifth Street, San Francisco, CA 94103, USA
CV
Lola Giusti is a graduate of the USC School of Dentistry. She is an Associate Professor with tenure at the Arthur
A. Dugoni School of Dentistry; she has taught as well as written in the fields of Removable Prosthodontics,
Radiology and Dental Ethics for fifteen years. Most recently she has published two articles on treating patients
with extreme caries risk due to substances such as methamphetamine in Decisions in Dentistry: The Journal
of Multidisciplinary Care and Dimensions of Dental Hygiene.
Questions
In the article, the question “Who should teach ethics?” has a couple of possibilities: “should
the subject be taught by.... ”. Which possibility is not correct?
qa. A dentist;
qb. A psychologist;
qc. A trained ethicist;
qd. A hygienist.
Graduates should know how to draw on a range of resources, among which are professional
codes, regulatory law, and ethical theories. These resources should not pertain to:
qa. Academic environment;
qb. Patient care;
qc. Practice management;
qd. Study.
Among the key ethical and professional values for a dental school graduate should not be:
qa. Dedication to care of patients;
qb. Empathy/honesty/ integrity;
qc. Respect for self and others;
qd. Self-interest.
All of the dental schools in the study utilized a common format to deliver content in Dental
Ethics courses, like:
qa. Lecture;
qb. Small group exercises;
qc. Panel discussions;
qd. Readings.
Stomatology Edu Journal 139