Class starts this coming monday and we were asked to come prepared to discuss dental ethics by completing an assignment that involved reading two articles and watching two summary videos of the topics discussed. These articles and videos can be found at
www.dentalethics.org. I have posted the material here as well.
Can Ethics Be Taught?
A Look at the Evidence
Muriel J. Bebeau, PhD
University of Minnesota
Some persistent myths about the teaching of ethics create a sense of hopelessness about the potential for influencing the ethical development of professionals. Both Dr. David Ozar and I have heard these myths countless times when discussing particular ethical problems of the profession, or when advising schools on the development of a program for ethics education. One such myth maintains the widely held belief that ethics and character are "hard-wired" sometime before puberty, and, you can't teach someone to be ethical after that. A second notion argues that even if you could teach ethics, no guarantee exists that people will practice ethically. A third idea assumes that people will only change through oppressive coercion or conversion.
Ethicists and educators who argue that ethics can be taught often rely on persuasive discourse to convince skeptics of the worth of the pedagogical enterprise.1,2 The arguments would be more effective if buttressed with research evidence on the impact of ethics education. I intend to present such evidence, findings drawn from the general literature on the psychology of morality, and from a dozen or more studies on the ethical development of dental students. These studies have been conducted over the past ten years by myself and my colleagues, Dr. James R. Rest and others, at the Center for the Study of Ethical Development. In presenting this evidence, I hope to undermine your confidence in the validity of some of these persistent myths and to show you why Dr. Ozar and I believe in the worth of the American College's initiative to increase awareness of ethical issues in the profession.
I begin by describing the reasons, drawn from psychological research3, which explain why people don't always do what others think they should. A review of these reasons demonstrates that effective ethical behavior results from a number of integrated abilities that characterize persons judged to be "of good moral character." Such an exploration helps us to understand the rationale for the goals of an ethics education program, as well as the rationale for teaching strategies that effectively develop the integrated abilities reflected in the goals. This review reveals why a program in professional ethics education needs to expand beyond the content of biomedical ethics. Even though this content is the very foundation for moral argument, the ability to construct a well-reasoned argument alone will not result in effective ethical behavior. In fact, the development of the ability to reason, in isolation from related abilities and implementation skills, often leads to the kind of cynicism we sometimes see in young professionals—professionals who haven't yet worked out ways of integrating the real with the ideal.
| A program in professional ethics education needs to expand beyond the content of biomedical ethics. |
Why Don't People Do What Others Think They Ought?
Psychological research3 indicates that individuals sometimes fail to do what others think they ought to do for four distinct reasons. First, an individual may be blind to the moral issues that present themselves. Individuals entering a new field of study, such as a profession, need to learn to integrate the technical information from the discipline with what they have come to know and understand about a professional's role and duty, as well as what they understand about the way their patient or client might behave. If a professional is insensitive to the needs of others, or if a situation is too ambiguous, the professional may fail to act morally.
Second, a person may be deficient in formulating a morally defensible course of action. History is replete with shocking instances of crooked thinking: Nazi officers' defense of the killing of millions of Jews on the basis of their duty to obey authority; Nazi physicians' justification of the use of concentration camp victims for lethal experiments; the US Public Health Services' continuation of the syphilis study after penicillin's invention; the A. H. Robins company's failure to inform the public of problems with the Dalkon Shield; etc...
Since professionals are often confronted with new and emerging dilemmas which have not been ajudicated, the ability to formulate a defensible course of action is a necessity. Case law indicates that professionals can be held accountable for the decisions they make. As a result, professionals are expected to be able to distinguish among competing values, to prioritize conflicting rights and to develop a morally defensible course of action.
| Professionals are expected to be able to distinguish among competing values, to prioritize conflicting rights and to develop a morally defensible course of action. |
But, knowing what one ought to do for moral reasons is, of course, no guarantee that one will do it. Third, an individual may fail to give priority to moral concerns. The dental profession worries about an oversupply of dentists and a decreasing incidence of disease, conditions which stress the professional's commitment to the interests of patients. The potential for this problem to have far reaching consequences for the profession and the public becomes even more apparent when we consider human nature. Each of us is capable of developing elaborate and internally persuasive rationalizations for prioritizing non-moral values over moral ones. Rest cites John Dean's confession in Blind Ambition, as an example of someone who has admitted that in his actions as special counsel to President Nixon, questions of morality and justice were preempted by more pressing concerns—Dean's desire to succeed in the Nixon administration.
| The dental profession worries about an oversupply of dentists and a decreasing incidence of disease, conditions which stress the professional's commitment to the interests of patients. |
Michael Josephson4 notes that rationalizations for prioritizing nonmoral values over moral values seem to be related to three kinds of selfishness: self-indulgence—the belief that one is entitled to the "good life" because one has suffered a lot to achieve one's professional status; self-protection—the desire to avoid unpleasant and embarrassing confrontations through lying, concealment, blameshifting and even document destruction; and self-righteousness—the tendency to judge ourselves in terms of our best and most noble virtues and motivations. Because self-esteem and self-respect depend on a positive assessment of one's own character, most of us believe we are ethical, even when an independent assessment of personal actions might prove otherwise.
| Because self-esteem and self-respect depend on a positive assessment of one's own character, most of us believe we are ethical. |
Finally, moral failings can result from an inability or unwillingness to implement an effective plan of action. Perseverance, competence and character are required to implement a plan of action. Poor interpersonal skills and poor problem solving abilities interfere with the effective resolution of a problem. Likewise, fatigue and lack of ego strength contribute to ineffectivity. Rest5 reminds us that ego strength can be used for good or evil. It comes in handy when confronting an incompetent colleague; it also comes in handy when robbing a bank.
If People Fail to Behave Morally for the Reasons Cited, What Can Be Done About It?
Rest5 contends that a carefully constructed set of educational experiences can be developed to strengthen abilities related to the four distinct failings. He does not suggest that an ethics program can transform scoundrels—even intensive psychotherapy may not be able to accomplish that. However, because most people want to be ethical and desire to be held in high regard by their peers, they want to develop competence in handling ethical problems. Entry to a profession should be based on an understanding of the values of the profession, and on a conscious commitment to uphold them.
| Entry to a profession should be based on an understanding of the values of the profession, and on a conscious commitment to uphold them. |
In Rest's view, the morally responsible professional: 1) recognizes moral problems as they arise; 2) judges which course of action is morally right (or fair or just or morally good); 3) prioritizes moral values ahead of personal interests and concerns; and 4) perseveres with sufficient ego strength and implementation skills to follow through on good intentions. A carefully crafted program in professional ethics will develop assessment strategies to measure attainment of each ability, and will create learning experiences to promote this attainment. If you examine some of the widely-disseminated goals for the teaching of professional ethics, you see some correspondence between these goals and Rest's Four Component Model of Morality3. The strength of Rest's model is the guidance it provides educators for understanding the relationship between cognition, affect and implementation skills. As you may know, the Curriculum Guidelines for Ethics in Dentistrv6 developed by the AADS in 1989, and supported by funds from the American College, were based upon Rest's model. The model also represents a major theoretical advance for psychological research, and has guided research on the ethical development of dental students.
So, what is the evidence that failure to behave morally isn't just a matter of scrupulous vs unscrupulous moral character, but actually relates to deficiencies that can be enhanced through carefully designed educational experiences? First, I must summarize what we have learned about problems of moral blindness from studies of professional school students' ability to recognize ethical problems in the situations they confront. I will hereafter refer to this ability as ethical sensitivity.
Research on Ethical Sensitivity
In 1980 we began a program of research to address these questions: Can ethical sensitivity be reliability assessed? Do students differ in ethical sensitivity? Can sensitivity be enhanced? And, is ethical sensitivity distinct from the ability to formulate a well-reasoned moral argument? Rest3 hypothesized that the two abilities were distinct from one another, and that the usual case-based approach for developing moral judgment abilities would be unlikely to develop ethical sensitivity. He thought that stimulus material to assess or develop ethical sensitivity needed to provide clues to a moral problem without predigesting or interpreting the problem as was typical of dilemmas designed to measure moral judgment or as was typical of cases used in ethics seminars.
Eight dramas were created for teaching and assessment. The issues and circumstances presented in the dramas were derived from dentists' reports of the frequently occurring ethical problems in dentistry7. The dramas were checked for realism and technical accuracy by dentists and other specialists. Dentists and auxiliaries were engaged to play the various roles, and the dramas were audiotaped. The dramas have been tested extensively8 by student groups and faculty and are perceived as realistic, relevant and stimulating cases for discussion. Four are included in the Dental Ethical Sensitivity Test (DEST),9 four others are included in the course materials available from the Center for the Study of Ethical Development.10
The validity and reliability of the DEST are reported in several studies,8,11-15 summarized both in the 1986,16 and in the 1990 version of the DEST manual.8 Validity and reliability are well enough established to support the following conclusions: 1) Ethical sensitivity can be reliably assessed. 2) Students vary greatly in their ability to recognize the ethical problems of their profession, and this ability is distinct from moral reasoning abilities. In other words, students may be skilled at interpreting 'the ethical dimensions of a situation (ethically sensitive), but unskilled at working out a balanced view of a moral solution (moral judgment), and vice versa. 3) Ethical sensitivity can be enhanced through instruction.13,14 Furthermore, the DEST is sensitive to institutional differences,14 and may be useful in evaluating the effectiveness of clinical programs.
| Students may be skilled at interpreting the ethical dimensions of a situation (ethically sensitive), but unskilled at working out a balanced view of a moral solution (moral judgment), and vice versa. |
Since new ethical issues emerge on a regular basis in the professions, the development of stimulus cases, modeled after the DEST cases, are an ideal way for the profession to keep abreast of newly-defined concerns. For example, just last summer, geriatric specialist Dr. Moshe Ernest17 developed five videotapes to assess general dentists' ability to recognize ethical issues involved in the care of medically and cognitively-compromised elderly. As with the DEST, he observed striking individual differences in students' and professionals'ability to recognize technical as well as ethical issues that would impact on their ability to deliver competent care.
Research on Moral Judgment
Given the evidence that professionals may benefit from experiences that sensitize them to ethical issues, is there evidence that engaging in discourse over the central values of the profession, as Dr. Ozar outlines them, influences the reasoning judgment process? Furthermore, if we influence the ability to develop a well-reasoned argument for a professional problem, can that ability influence behavior? These questions seem to be the central concerns at the basis of our "second myth."
| ". . . a large body of psychological research . . . contradicts the widely-held belief that young adults hold firm and immutable value systems that dictate the ethical quality of their conduct." |
Rest, in a 1986 summary18 of well-established findings from psychological research on moral judgment development and its relation to moral action, concludes: ". . . a large body of psychological research . . . contradicts the widelyheld belief that young adults hold firm and immutable value systems that dictate the ethical quality of their conduct." I have selected from Rest's summary a discussion of findings which are of particular interest. I have supplemented Rest's conclusions with findings from research with dental students.
1. Dramatic and extensive changes occur in young adulthood in the basic problem solving strategies used by persons in dealing with ethical issues.
Studies18 show that major ethical development occurs after adolescence. Actually, the mental capacity to engage in relatively sophisticated moral reasoning generally does not develop until the late teens and early twenties. Dramatic changes in problem solving abilities are evident among professional school students, even among older students.19
2. Changes in problem solving strategies are linked to fundamental reconceptualizations in how a person understands society and his or her stake in it.
Kohlberg20 has observed that people at various points of development interpret moral dilemmas differently: they define the critical issues of the dilemma differently, and have different intuitions about what is right and fair in a situation. Kohlberg's "stage theory" articulates the way persons at specific points in development conceptualize the relationship between their own interests and the interests of others. In the earliest stages, people (especially children) focus mainly on self-interest in decision making. Gradually, people begin to understand the on-going interests of others and are moved to consider these interests in decision making. At the more advanced conventional stages of development, individuals use existing laws to guide their actions; they recognize that, in a law-oriented society, everyone both benefits and is protected by the law.
Persons at post-conventional levels of development understand existing laws to have limitations; moreover, our system of governance has a process for examining rules and law. Law-making processes are designed to reflect the general will of the people while insuring certain basic rights. Actions are guided by the obligation to abide by the arrangements agreed upon by due process. As development continues, the individual begins to recognize the limitations of due process, that even due process can result in injustice. This individual makes decisions based on a general principle that one is obligated, not necessarily to what has been agreed upon by due process, but to what rational nonarbitrary people would agree is moral. At these stages of development, individuals apply moral principles to complex moral problems.
Research indicates that changes in how a person understands society and his or her stake in it are not just fluctuations in attitude. People who do not apply principled considerations (like justice or autonomy or beneficence) to complex problems tend not to understand those ideas. People who understand the ideas tend to use them in decision making. Of particular interest to the teaching of professional ethics is the finding that changes in reconceptualization do transfer to new situations. People do alter fundamental value systems in response to experience and op= portunities for reflection. Even mature professionals change their mind on ways to resolve dilemmas in their profession.
One of the more frequently used measures of moral development, the Defining Issues Test,21 measures the proportion of times an individual selects arguments that appeal to moral principles, rather than to existing rules or to self-interests, as he or she tries to resolve complex social problems. On the average, dental and medical students select principled considerations about 50 percent of the time, while graduate students in moral philosophy and political science do so 65 percent of the time. The average adult selects principled considerations about 40 percent of the time, while high school seniors do so 32 percent of the time. Delinquent adolescents choose them even less often, 18 percent of the time.
As with ethical sensitivity, the dental student's ability to apply principled considerations to moral problems varies considerably. Given the diversity present in the general population, we might expect such diversity in the professional population as well.
I use the Defining Issues Test (DIT) as a pretest for beginning students, to give them insight as to how well their ability to recognize principled considerations has developed at the point of entry to professional school. They retake the test at the end of the four year curriculum to assess their growth. Although the results do not imply whether or not a person is moral, the results help a person decide how much confidence he or she ought to have in his or her intuitions about what is right and fair.
Dr. Ozar points out that any program in professional ethics needs to examine instances when one should conscientiously disobey one's professional duty. I've noticed that the cases students see as ethically challenging are not the cases faculty find challenging. Given the variability in people's ability to apply principled considerations to complex problems, it seems prudent for the educator to involve ethics education participants, whether students or professionals, in the selection of dilemmas for discussion.
3. College education is powerfully associated with development of moral judgment.
In general, development continues as long as a person is in a formal educational setting. Development tends to plateau when a person leaves school. Persons with high moral judgment scores tend to be more reflective, more interested in their development, more likely to continue their education. They are more interested in wider social issues and are more active in community affairs. Dental students with high moral judgment scores give higher ratings to courses in professional ethics.19 If ethics courses are offered as electives, a move implying that these courses are not necessary to the dental profession, then the courses may not draw the student population most in need of instruction. Likewise, if ethics topics are competing with clinical topics at state or national meetings, they may only attract those with the time and inclination to reflect on the broader professional issues.
4. Deliberate educational attempts to influence awareness of moral problems and to influence the reasoning/judgment process are effective.
| Persons with high moral judgment scores tend to be more reflective, more interested in their development, more likely to continue their education. |
Educational programs emphasizing peer discussion of controversial moral dilemmas produce significant gains, especially for students in their 20s and 30s. Discipline-oriented, information-laden courses in philosophy and ethicsrelated disciplines seem not to be so effective. Also, classroom interventions shorter than three weeks do not seem effective; however, programs exceeding 12 weeks do not increase gains proportional to the time spent. The Minnesota curriculum, consisting of 39 contact hours distributed over four years,22 has been shown to be effective in promoting moral reasoning abilities and positive attitudes toward ethics education,19 but undergraduate preparation in philosophy and the humanities has not predicted moral judgment scores for beginning dental students. Furthermore, such undergraduate preparation has not moderated the, change in moral judgment that has occurred during professional school.23
5. Differences between males and females in moral judgment and ethical sensitivity are trivial.
Carol Gilligan's view that women appear less sophisticated in the use of justice concepts than males is not at all supported, as Rest cites, either by reviews of psychological research,18 or by the large scale meta analysis he and his colleagues have conducted (see chapter 4). In fact, in objective measures like the DIT, females score higher than males. In reality, level of education is the most powerful predictor of moral judgment scores, not gender. A study13 investigating gender differences in professional school students'ethical sensitivity and moral reasoning indicates that men and women differ in general sensitivity to ethical issues, but not in recognition of the care or justice issues embedded in the test, nor in moral judgment. In the aggregate, women have a slight edge in recognizing the ethical issues of the dental profession, but some women are as blind to ethical issues as their male colleagues, and all can benefit from ethical sensitivity training.
| Differences between males and females in moral judgment and ethical sensitivity are trivial. |
6. Religion is related to moral judgment when represented in terms of conservative versus liberal ideology.
Liberal religious ideology is associated with higher DIT scores, perhaps because these ideologies emphasize the individual's own responsibility in determining a just balance of claims in a moral dilemma, whereas the more conservative ideologies emphasize obedience to external authority and doctrines. Lawrence noted that fundamentalist seminarians were capable of mature justice reasoning, but neglected to use those ideas in taking the DIT. When asked how they made moral decisions, these subjects said they relied on religious directives to resolve the test's dilemmas.
7. Studies link moral perception and moral judgment with actual real-life behavior.
While certainly no guarantee exists that improvements in reasoning brought about by courses in ethics will assure ethical behavior, a review of over 50 studies shows moral judgment to be significantly related to a wide variety of behavioral and attitudinal measures. The measures include behaviors such as cooperative behavior, distribution of rewards, cheating, conscientious objection, clinical performance ratings of medical interns, delinquency, and school problem behavior. A wide range of attitudes (toward authority, death, discipline, capital punishment, etc.) is also linked to moral judgment. Studies to date have not explored whether some of the unexplained variance in those behavioral and attitudinal measures could be attributed to ethical sensitivity or the implementation abilities described in Rest's fourth component.
Research on Motivation and Commitment to a Professional Role
Research has not proceeded very far in figuring out how to assess the motive strength of an individual in a given situation. Yet some connections appear between cognition and affect that suggest ways to influence commitment. Though we lack understanding of what motivates the selection of moral values over other values, rationalizations to prioritize non-moral values over moral values can certainly be challenged, and peoples' commitment to priviledge one value over another can often be traced to their perceptions of their roles.
Dr. Ozar outlines three models of professionalism that reflect distinctly different prioritizations of professional values. In studying students' understanding of the role of a professional,24 we noted in their responses that key concepts distinguishing a profession from other occupations were not well developed prior to professional school. Through lecture and response to essays, faculty enhance the students' ability to discuss the professional role. But, the concepts of self-regulation, service to society, and the basic duty to place patient's rights before self-interest are still frequently omitted or miscommunicated by as many as 20 percent of the students.
Concept learning is not a matter of rote memorization but of reconstruction. Students with no functional schema for certain concepts are not able to reconstruct the ideas in a way that conveys similar meaning. Therefore, several educational experiences may be necessary to instill a clear concept of the professionals'role.
Research on Self-Regulation and Implementation Skills
Some research on self-regulation processes illustrates the relation between cognition and affect. If persons think of a task as "fun" or "challenging," they are more likely to persist in their efforts to resolve the problem. Conversely, if they approach a problem with dread, they are less likely to persevere. Practice in resolving difficult problems of the profession—like responding to an apprehensive or angry patient, or discussing a quality issue with an offending peer, can change the expectations of efficacy that are likely to change behavior.
At Minnesota, we involve students in roleplaying exercises that build competence and confidence in resolving ethical problems. Such experiences may determine whether or not actions to resolve a problem will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles and adversive experiences. In each encounter with students, I try to promote John Ruskin's ideal that what is important about our work is not what we get from it, but what we become by it.
| I try to promote John Ruskin's ideal that what is important about our work is not what we get from it, but what we become by it. |
Summary
A substantial body of research contradicts the persistent myths about the potential for influencing the ethical development of mature professionals and professional students. Engaging in carefully planned educational activities promotes abilities related to behavior. Professionals who persist in promoting these myths are not likely to mobilize themselves to engage in the efforts the American College has undertaken to stimulate reflection on the values of the profession and to influence the way these ideals are applied in practice.
References
- Hastings Center, The Teaching of Ethics in Higher Education, Hastings-onHudson, New York, 1980.
- Bok, D.C., Can Ethics Be Taught?, Change Magazine, pp. 26-30, October 1976.
- Rest, J., Morality, In Manual of Child Psychology (edited by P. Mussen), Vol. 3: Cognitive Development, Edited by J. Flavell and E. Markham, pp. 556-629, New York: Wiley, 1983.
- Josephson, M., Teaching Ethical Decision Making and Principled Reasoning, Ethics: Easier Said than Done, 1(1): 27-33,1988.
- Rest, JR., A Psychologist Looks at the Teaching of Ethics, The Hastings Center Report, 12(t):29-36,1982.
- Curriculum Guidelines on Ethics and Professionalism in Dentistry, Journal of Dental Education, 53(2):144-8, 1989.
- Bebeau, M.J., Reifel, N.M., and Speidel, T.M., Measuring the Type and Frequency of Professional Dilemmas in Dentistry, Journal of Dental Research, Vol. 60, Program and Abstracts, Abstract No. 891, March 1981.
- Bebeau, M.J., Rest, J.R., and Yamoor, C.M., Measuring Dental Students' Ethical Sensitivity, Journal of Dental Education, 49(4):225-35, 1985.
- Bebeau, M.J. and Rest, J.R., The Dental Ethical Sensitivity Test, Division of Health Ecology, School of Dentistry, University of Minnesota, 1990 Edition.
- A Professional Responsibility Curriculum for Dental Education, Center for the Study of Ethical Development, University of Minnesota, 1990 Edition.
- Bebeau, M.J., Oberle, M., and Rest, JR., Developing Alternate Cases for the Dental Ethical Sensitivity Test (DEST), Program and Abstracts, Abstract No. 228, Journal of Dental Research, 63:196, March 1984.
- Tsuchiya, T., Bebeau, M.J., Waithe, M.E., and Rest, JR., Testing the Construct Validity of the Dental Ethical Sensitivity Test (DEST), Program and Abstracts, Abstract No. 102, Journal of Dental Research, 64:186, 1985.
- Bebeau, M.J., and Brabeck, M.M., Integrating Care and Justice Issues in Professional Moral Education: A Gender Perspective, Journal of Moral Education, 16(3):189-203, 1987.
- Baab, D.A., and Bebeau, M.J., The Effect of Instruction on Ethical Sensitivity, Journal of Dental Education, 54(1):44, 1990.
- Harvan, R.A., The Relationship Between Technical Competence and Ethical Sensitivity Among Health Professionals, Unpublished Doctoral Dissertation, Rutgers, The State University of New Jersey, 1989.
- Rest, JR., Bebeau, M.J., and Volker, J., An Overview of the Psychology of Morality, In: Rest, J.R. (Ed.), Moral Development: Advances in Research and Theory, pp. 1-39, Boston: Praeger Publishers, 1986.
- Ernest, M., Developing and Testing Cases and Scoring Criteria for Assessing Geriatric Dental Ethical Sensitivity, Unpublished Thesis, University of Minnesota, 1990.
- Rest, JR., and Associates, Moral Development: Advances in Research and Theory, New York: Praeger Publishers, 1986.
- Bebeau, M.J., The Impact of a Curriculum in Dental Ethics on Moral Reasoning and Student Attitudes, Journal of Dental Education, 52(1):49, 1988.
- Colby, A., Kohlberg, L., and Collaborators, The Measurement of Moral Judgment, Vol. I, Theoretical Foundations and Research Validation, Cambridge: Cambridge University Press, 1987.
- Rest, J.R., Development in Judging Moral Issues, Minneapolis: University of Minnesota Press, 1979.
- Bebeau, M.J., Teaching Ethics in Dentistry, Journal of Dental Education, 49(4):236-43, 1985.
- Bebeau, M.J., and Waithe, M.E., Undergraduate Preparation in Philosophy, Humanities, and Social Sciences as Pre dictors of the Ability to Identify and Reason About Ethical Issues in Dentistry, Journal of Dental Education, 52(1):49, January 1988.
- Bebeau, M.J., Using Classroom Assessment to Improve Instruction in Ethical Decision Making: Two Data-Based Examples, Paper Presented at the Annual Meeting of the American Educational Research Association, Boston, MA, April 1990.
*Muriel J. Bebeau, Ph.D., Associate Professor School of Dentistry, Director of Education, Center for Study of Ethical Development, University of Minnesota. A presentation made at the ACD Section Representatives Meeting October 11, 1990 in Boston.
Video 1—Can Ethics Be Taught? by Muriel J. Bebeau, PhD (21:31)
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Part II
A Framework for Studying Professional Ethics
David T. Ozar, PhD
Loyola University of Chicago
As you know, the leadership of the American College of Dentists has been working for more than a year on a major educational initiative in the area of professionalism and professional ethics. Today's program is the first fruit of these efforts. But if they are successful, they will yield far more, including a two or three-day training workshop on professional ethics and professional ethics education for representatives from every Section of the College and a systematic effort built on that workshop to stimulate the discussion of ethical issues in dentistry at the local level throughout the country.
The aim of today's program is to explain to you what is possible when professional ethics education is undertaken in a careful and systematic way. I will do this from the perspective of the content of a program in professional ethics in dentistry. Dr. Muriel Bebeau will do so from the perspective of educational goals and learning strategies which ensure that the content gets applied in professional practice. The emphasis today will be on professional ethics education, rather than on the issues of professional ethics themselves. You may well wish that there were more time today to examine the issues that we use as examples, many of which have been suggested by yourselves. But careful discussion of these issues is what will go on in the training workshop and in the programs that we hope will be conducted throughout the country as a result of it. Here I will focus on the content of such programs themselves.
What Dr. Bebeau and I will be doing here is sharing the fruits of ten years or so of professional ethics education in our respective dental schools and in numerous lectures and workshops that we each have given for groups of dentists all over the United States and Canada. We know from our own experience, and the experience of others who teach in this area, that professional ethics education can be very effective. But we, and Dr. Biddington and the other members of the College involved in this project, also know that many people believe that ethics and a sense of professionalism cannot be taught. So it is important, at the outset of this project of the College, to explain what is possible in professional ethics education, when it is done in a careful, systematic way.
I will shortly describe seven categories that I use to clarify the contents of dentists' professional obligations. I have developed these categories from studying not only professional ethical issues that arise in dentistry, but from my study of many professions over the last fifteen years. One of the sad things about American professions is their tendency towards parochialism. It is absolutely clear to me, from my studies of many professions, that the professions have a great deal to learn from each other. This is particularly true of professions that work in a common area of human life, like the health professions. These seven categories are the first fruits of my effort to draw together a common picture of the professions, a careful statement of what our professions have in common.
Some Preliminary Questions
Before I discuss the seven categories, however, I need to identify several assumptions that I will simply set down as assumptions here today, but that would be carefully discussed in any sound educational program on professional ethics. First, I will take it for granted here that to be a member of a profession means that one has undertaken certain obligations. The purpose of the seven categories is to help clarify what sorts of obligations these are. But a more basic question is whether one can be a professional and not have special obligations as a result. Some professionals, and some theorists about professions, argue that this is the case. But I hold, as I am sure you do, that being a professional entails having obligations. There is no time to examine the arguments for and against this view here today. But, as I said, any sound educational program on professional ethics would examine these arguments carefully.
| To be a member of a profession means that one has undertaken certain obligations. |
Secondly, I am obviously assuming that dentistry is a profession, and I am sure you think this is so as well. But this too is a fundamental question that a careful examination of dentists' professional obligations would have to include. We would have to ask just what a profession is, and why professionals have obligations, and then ask whether dentistry and dentists conform to the answers we give to these questions. If we did not include these fundamental questions in our examination of professional ethics in dentistry, our understanding of the basis of dentists' professional obligations would surely be lacking.
Thirdly, I will assume something here that I am not sure you would agree with, but which we do not have time to examine carefully today either. Some people take the view that the content of a profession's obligations is determined by the members of that profession and no one else. My view is rather that the content of a particular profession's obligations at a given point in time is the product of a dialogue between the profession and the larger community; it is not determined by the profession alone. This dialogue is subtle, complex. It is ongoing in time; and it is rarely explicit or formal. But it is nevertheless the source of the contents of dentists' professional obligations. As a consequence, you can never adequately determine what are your obligations as a dentist simply by asking what dentists say about the situation or what organized dentistry says about it. You must also ask what the larger community understands dentists to be committed to. This may seem a vague and often frustrating test of one's professional obligations; but if those obligations are in fact the fruit of a dialogue with the larger community, as I believe they are, then it is a test that may not be set aside.
| Professions' obligations are not the product of the profession alone, but are the fruit of an ongoing dialogue between the dental profession and the larger community. |
This fundamental question about the source of professional obligations would also have to be care fully examined and the arguments on both sides evaluated on their merits in a carefully constructed program of professional ethics education. But today I will resolve the issue for my purposes by again making an assumption, namely that professions' obligations are not the product of the profession alone, but are the fruit of an ongoing dialogue between the dental profession and the larger community.
Already you should be able to see that there is plenty to talk about and think about when professional ethics is being taught. It is not the place of the teacher to simply recite to students the "Answers" to such difficult questions, particularly when there are thoughtful arguments on both sides of each of these questions. The learner needs rather to be brought to think about these questions, about the arguments that have been given on all sides of them, and about the implications of various answers to them for dental practice.1 Ultimately, every dental practitioner will have to form his or her own answers to these fundamental questions, for they will affect the way he or she thinks and practices. The teacher's role is to bring each learner, whether dental student or established practitioner, to a reflective understanding of the reasons he or she has for answering each of these questions in a certain way, and to make certain that the learner has confronted others' views and the reasons they offer in turn.
The same is true when we look to place a dentist's professional obligations in context. The general topic of moral or ethical decisionmaking is much too broad to even summarize here. But the point needs to be raised that a person's other obligations may come in conflict with his or her professional obligations in a particular situation. Is it the case that the professional obligations always "win"? Are they always the determining factors of what the person ought to do when all things are considered? I shall offer a fourth assumption here, because I judge it to be the case, that one's professional obligations are not necessarily absolute. They do not always determine what we ought to do; other obligations can sometimes outweigh them. As is the case with other role-based obligations, we can be in situations in which it is perfectly clear that our professional obligation is to do X, but we have other obligations to do Y instead and these latter obligations are more important. Under such circumstances, I am assuming, we are not only morally or ethically justified, but may even be morally or ethically required to conscientiously disobey our professional duty. This is another issue that needs to be carefully examined in any sound program of professional ethics education.
| One's professional obligations are not necessarily absolute. They do not always determine what we ought to do; other obligations can sometimes outweigh them. |
Seven Categories of Professional Obligation
With these points set down in the form of assumptions, mostly to make clear how important are the questions they relate to, let me now turn to the promised seven categories of professional obligation. There are probably other useful ways of dividing the general topic of professional obligation besides this one. But I have found it useful in the study of many professions and informative in particular in the study of dentistry.
1. The Chief Client
Every profession has a chief client or clients. This is the person or set of persons whose wellbeing the profession and its members are chiefly committed to serving. The dentist's chief client would seem to be the patient, pure and simple.
But consider lawyers for a moment. Who is the lawyer's chief client? Is it simply the party whose case the lawyer represents and pleads? Lawyers are told and announce in their self-descriptions and codes of conduct that they have obligations to the whole justice system, and therefore that there are things that they may not ethically do, as professionals, even if doing them would advance the case of the party they represent. So it appears that the answer to the question about the chief client of the lawyer is complex, involving both the person they represent and the whole justice system, or perhaps the whole larger community whom that system serves.
Could the dentist's situation be similarly complex? Does a dentist have a professional obligation to the public, to protect the public from a serious health risk, for example in the case of a patient with a serious communicable disease? Is there such an obligation and can it ever outweigh the dentist's obligation to his or her patient; for example, can it outweigh the dentist's obligation of confidentiality regarding information about a patient?
2. The Relationship between Professional and Patient
The point of the relationship between a professional and a client is to bring about certain values for the client, values that cannot be achieved for the client without the expertise of the professional. Bringing about these values will require both the professional and the client to make a number of judgments and choices together. The question that this category addresses concerns the proper relationship between the professional and the client as they make these judgments and choices together.
At least four general models of such relationships can be distinguished: a Commercial Model, which mirrors the relationship of producers and consumers in the commercial market place; a Guild Model, in which the emphasis is on the professional's expertise and the client's lack of it, so that the active member in all judgments and choices about professional services for the client is necessarily the professional alone; an Agent Model, in which the expertise of the professional is placed at the service of the values and goals of the client without exception; and an Interactive Model, in which both parties have unique and irreplaceable contributions to make in their judgments and choices together and in which both the client's and the professional's values serve as determinants of what they do.2
Which of these four models is the proper model of the relationship between dentist and patient? What are their implications for actual practice? Is the goal of patients having informed consent to treatment adequate or does the ideal relationship involve more than this? What are the obligations of patients in the ideal relationship and how can patients be educated in these obligations? Where do such economic factors as cost, the patient's ability to pay, the dentist's need to continue in business, etc., fit into the ideal relationship if the Commercial Model is inadequate on its own? How can dentists preserve the proper relationship with their patients when third parties like insurance companies have so much power to affect treatment?
In addition, what is the proper relationship between the dentist and the patient who is incapable of participating in treatment decisions? What is the role of the patient's guardian or other responsible party, and how is the dentist to proceed when his or her professional judgment about the patient's wellbeing differs from what the guardian or responsible party chooses? What is the proper role for the dentist in making treatment decisions with and for a patient with genuine but limited ability to participate?
Answering these questions, not only in general terms, but in relation to cases from dentists' actual practice is one of the most important learning experiences we can provide to those who want a more careful understanding of a dentist's obligations as a professional.
3. A Hierarchy of Central Values
Every profession is focused only on certain aspects of the wellbeing of its clients. It is not the client's entire wellbeing, and it is not everything that is valuable, that a professional is committed to secure for the client. Rather there is a certain set of values that are the focus of each profession's expertise and that it is the job of that particular profession to secure for clients. These I call the central values for that particular profession.
I have argued elsewhere3 that the central values that the dental profession is committed to pursuing for its patients are, in this order: (1.) life and general health; (2.) oral health, understood as appropriate and pain free oral functioning; (3.) autonomy, i.e. the patient's control, if he or she is able, over what happens to his or her body; (4.) preferred patterns of practice on the part of the dentist; (5.) aesthetic considerations; (6.) considerations of cost and efficiency from the dentist's point of view.
Are these indeed the central values of the dental profession, or are there others that I have missed? Are any of these not central, so they should be removed from the list? Do these values indeed form a hierarchy, and if so, is the ranking I have given correct?
To give a few examples, if a patient is well informed that a particular treatment is not in his or her best interest, but for personal reasons the patient wants the treatment anyway, may a dentist professionally provide it? May the dentist emphasize more profitable treatments which are not so time-tested as less profitable ones but are within the dental communities accepted standards of minimal care? May patients' dental health be marginally sacrificed for the sake of aesthetic benefits?
Answering these sorts of questions, and applying them to cases drawn from actual practice is a valuable way to illuminate dentists' professional obligations.
4. Competence
Every professional is obligated both to acquire and to maintain the expertise needed to undertake his or her professional tasks; and every professional is obligated to undertake only those tasks that are within his or her competence. This is probably the most obvious category of professional norms; and it is the easiest to describe in a few words. But the determination of what counts as sufficient or minimally adequate competence on the part of a member of a given profession, both in general and in relation to specific kinds of tasks, is a very complex question. Is dentistry right to recognize a variety of clinically acceptable, but very different kinds of treatment for many kinds of dental care needs? What standard of certainty is a dentist obligated to apply when determining whether he or she is capable of handling a particular procedure?
5. The Priority of the Client's Wellbeing
Most sociologists who study professions mention "commitment to service" or "commitment to the public" as one of the characteristic features of a profession. Similarly, in most professions' self-descriptions, in their codes of ethics and the like, priority of service to the public is given prominent place. But these expressions admit of many different interpretations with significantly different implications for actual practice.
On what could be called a "minimalist" interpretation of this norm, dentists would have only an obligation to consider the wellbeing of their patients to be among their most important concerns. On the other hand, on a "maximalist" interpretation dentist's commitment to the priority of the patient's wellbeing would mean that he or she has an obligation to place the wellbeing of the patient ahead of every other consideration, both the dentist's own interests and all other obligations or concerns that he or she might have regarding any other individual or group. There are a number of intermediate interpretations of this norm as well.
What sorts of sacrifices are dentists professionally committed to for the sake of their clients? May a dentist decline to treat an HIVpositive patient out of fear of infection? Are dentists professionally obligated to provide needed care, even at considerable financial sacrifice, if a patient cannot pay for it? If so, what is the extent of this obligation; how great a sacrifice is professionally required of the dentist?
6. Relations With Co-Professionals
Each profession has norms, usually largely implicit and unstated, concerning the proper relationship between members of the profession. Should dentists relate to other dentists in the same area of practice as competitors in the marketplace? Or should they work to support one another's practices even if patients have to pay more as a result? Or is there some third way of relating that is better than either of these? How should a dentist deal with another dentist's inferior work? Should he or she protect the other dentist, or report the other dentist, inform the patient or not, contact the other dentist or not?
In addition, these include relationships between members of different professions who care for the same patients. What are the proper relationships between dental care givers who have different areas of specialization and expertise? How do these co-professional relationships connect with the relationship between employer and employee that often is equally relevant? Which relationship should take precedence and how?
7. Relations Between the Profession and the Larger Community
In addition to relationships between professionals and their clients, the activities of every profession involve relationships between both the profession as a group and its members and the larger community as a whole or various significant subgroups of it. What obligations does dentistry have, and what obligations do individual dentists have to the larger community regarding inferior work or unethical practice? How should the dental community deal with its members who are substance-dependent or substance-abusers? What is the individual dentist's obligation when he or she knows of such a problem about another dentist in the community?
What is the proper standard for professional advertising? How much understanding of marketing techniques and "puffery" in advertising can the dental community presume of the lay public?
How strong an obligation do dentists have to provide or to refrain from providing expert testimony in court cases involving other dentists? Do dentists have special public health obligations when the larger community faces a serious epidemic? Are dentists obligated to reveal their own HIV-status to the public or to prospective or current patients?
What obligations does the public have towards dentists who care for infected persons?
What is the proper role and content of dental organizations' codes of conduct? Who should participate in the design and amendment of these codes? How should these codes be enforced?
The list of difficult questions under this heading and in each of these categories is obviously very long; and just distinguishing them carefully from other sorts of questions does not answer them. But distinguishing them and thus clarifying their content makes them more amenable to careful reflection and to thoughtful judgment about how an ethical dentist ought to act in regard to them.
Conclusion
One of the first goals of professional ethics education, whether in dental school or in continuing dental education or in more informal, cooperative learning projects within the profession, is to provide dentists with conceptual tools that will help them reflect more clearly on the ethical issues that concern their professional practice. By using conceptual tools like the seven categories and the preliminary questions discussed before them, dentists can keep their questions clear and apply a clearer understanding of the ideals of professional practice in dentistry in their reflections on them. In this way, not only individual dentists, but the dental community together, can work towards clearer and better answers to the sorts of questions that you have listed as particularly important to you and that I have used as my examples here. This is one of the ways in which the American College of Dentists professional ethics education project can contribute to more constructive ethical reflection and more reflective ethical behavior on the part of American dentists.
References
- D.T. Ozar, Formal Instruction in Dental Professional Ethics, Journal of Dental Education, 49:696-701, October, 1985.
- The Commercial, Guild, and Interactive Models are discussed in detail in Ozar, D.T. Three Models of Professionalism and Professional Obligation in Dentistry," Journal of the American Dental Association," 110:173-177, February, 1985.
- Ozar, D.T., Schiedermayer, D., and Siegler, M., Value Categories in Clinical Dental Ethics, Journal of the American Dental Association, 116:365-368, March, 1988.
*David T. Ozar, Ph.D, Associate Professor, Department of Philosophy and School of Dentistry, Loyola University of Chicago. A presentation made at the ACD Section Representatives Meeting October 11, 1990 in Boston.
Video 2—A Framework for Discussing Ethics by David T. Ozar, PhD (10:27)
Select the desired format and your connection speed:
Bebeau, MJ. Can Ethics Be Taught? A Look at the Evidence. Journal of the American College of Dentists, 1991, 58, 5,10-15; Ozar, DT. A Framework for Studying Professional Ethics. Journal of the American College of Dentists, 1991, 58, 4,6-9. The two videos are part of "An Ethics Education Program for Practicing Dentists" commissioned by the American College of Dentists in 1992. The instructor manual for this program was developed by Muriel J. Bebeau, PhD, University of Minnesota.
