An Ethics Education Program for Practicing Dentists

encompassing “Can Ethics Be Taught?” and “A Framework for Discussing Ethics.” (1 credit hour)

Learning Objectives

After completing the course, participants will understand:

• The evidence that ethics can be taught, including the research on ethical sensitivity, moral judgment, motivation and commitment to a professional role, and self-regulation and implementation skills
• Why people don’t do what others think they should
• The goals of an ethics education program for practicing dentists
• The content of professional ethics education programs
• The seven categories of professional obligations

Please Review the Following Material:

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 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.

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 adjudicated, 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.

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.

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.

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 ineffective. 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 upholding 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, affects 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? Rest³hypothesized 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 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.

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 Ernest¹⁷developed 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.”

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 widely-held 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 ensuring 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 opportunities 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 pretext 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. A college education is powerfully associated with the 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.

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 ethics-related 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, the 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.

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 variances 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 privilege 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 a 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 effect. 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 adverse experiences. In each encounter with students, I try to promote John Ruskin’s idea 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

1. Hastings Center, The Teaching of Ethics in Higher Education, Hastings-onHudson, New York, 1980.
2. Bok, D.C., Can Ethics Be Taught?, Change Magazine, pp. 26-30, October 1976.
3. 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.
4. Josephson, M., Teaching Ethical Decision Making and Principled Reasoning, Ethics: Easier Said than Done, 1(1): 27-33,1988.
5. Rest, JR., A Psychologist Looks at the Teaching of Ethics, The Hastings Center Report, 12(t):29-36,1982.
6. Curriculum Guidelines on Ethics and Professionalism in Dentistry, Journal of Dental Education, 53(2):144-8, 1989.
7. 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.
8. Bebeau, M.J., Rest, J.R., and Yamoor, C.M., Measuring Dental Students’ Ethical Sensitivity, Journal of Dental Education, 49(4):225-35, 1985.
9. Bebeau, M.J. and Rest, J.R., The Dental Ethical Sensitivity Test, Division of Health Ecology, School of Dentistry, University of Minnesota, 1990 Edition.
10. A Professional Responsibility Curriculum for Dental Education, Center for the Study of Ethical Development, University of Minnesota, 1990 Edition.
11. 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.
12. 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.
13. 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.
14. Baab, D.A., and Bebeau, M.J., The Effect of Instruction on Ethical Sensitivity, Journal of Dental Education, 54(1):44, 1990.
15. 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.
16. 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.
17. Ernest, M., Developing and Testing Cases and Scoring Criteria for Assessing Geriatric Dental Ethical Sensitivity, Unpublished Thesis, University of Minnesota, 1990.
18. Rest, JR., and Associates, Moral Development: Advances in Research and Theory, New York: Praeger Publishers, 1986.
19. 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.
20. Colby, A., Kohlberg, L., and Collaborators, The Measurement of Moral Judgment, Vol. I, Theoretical Foundations and Research Validation, Cambridge: Cambridge University Press, 1987.
21. Rest, J.R., Development in Judging Moral Issues, Minneapolis: University of Minnesota Press, 1979.
22. Bebeau, M.J., Teaching Ethics in Dentistry, Journal of Dental Education, 49(4):236-43, 1985.
23. Bebeau, M.J., and Waithe, M.E., Undergraduate Preparation in Philosophy, Humanities, and Social Sciences as Predictors of the Ability to Identify and Reason About Ethical Issues in Dentistry, Journal of Dental Education, 52(1):49, January 1988.
24. 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.