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for the others. These values were identified as
central among the desired characteristics of a
graduate from the institution. 11
Another question involves the impact of teaching
and learning in this content area: Do students
change their thinking as a result of ethics
instruction? A preliminary study carried out at
the University of Istanbul indicates an affirmative
conclusion. 13 Case scenarios were presented to
fourth year students (n=37) who were presented
with a four topics approach to clinical ethics
(medical indication, patient preferences, quality of
life, and contextual features), and asked to solve
the case using their knowledge of ethics, which
they had gathered from a lecture in their third year.
Thereafter students received a three-hour lecture
on the four topics approach, used for clinical ethical
case analysis. After completion of the lecture, the
same case scenario was presented to the students
again. There was significant development in
the students’ performance after the course. The
authors provide evidence that ethical decision-
making can indeed be taught and learned within
the framework of a dental school course.
This topic was also investigated by faculty in the
fields of business and accounting. Two studies
published in the Journal of Business Ethics in
2015 demonstrate interest in the impact of ethics
education upon student behavior. The first study,
published by Martinov-Bennie and Mladenovic
(2015), analyzed how accounting students develop
ethical sensitivity and ethical judgment. Their
findings indicate that the existence of a framework
alone does not appear to increase ethical sensitivity,
but that an integrated ethics component using
case studies can increase ethical sensitivity. Ethical
judgment was similarly affected by the integrated
education program. The second study , done at
West Chester University of Pennsylvania with
undergraduate business students, researched the
roles of gender, personal ethical perspectives, and
moral judgment in business ethics instruction. 14
The findings demonstrated there was variability
connected to the type of ethical dilemma, and some
effect linked to gender, but no main effect of each
factor. The authors discussed their conclusions
by stating (page 600), “Finally, we would like to
reiterate a concern of other researchers that the
way in which students respond to ethical dilemmas
in the classroom may not be indicative of how they
will react to ethical challenges in the real world.”
For example, the analysis of whether or not the
ethics curricula are effective has been vigorously
debated by Bertolami and Jenson. 15,16 Spirited
analysis of academic dishonesty promoted
national discussion. In responding to Bertolami’s
assertion that students continue to cheat in spite
of the existence of dental ethics courses, Jenson
maintained that (page 227):
“…dental ethics courses, as they are now taught,
are essential and valuable. Could they be better?
Absolutely. Could they actually provide students
with the moral courage needed to make the right
ETHICS INSTRUCTION AT CALIFORNIA DENTAL SCHOOLS
choices when they already know right from wrong?
This is an open question and one that deserves
some empirical research.”
The authors of this paper assert that ongoing
efforts to assess and improve ethics instruction in
dental education are essential. The dental schools
that participated in this research respond to the
charge of educating ethical practitioners through
the practices described below.
2. Methods
The Institutional Review Board approval was
obtained for the unfunded project, with expedited
review. Faculty members identified as Dental Ethics
Course Directors at four California schools were
contacted by phone to enlist their participation
in a qualitative study. After completion of the
Informed Consent processes, faculty members
from four of the schools completed an electronic
survey (see Appendix 1) and respondents
attached relevant course documents. The survey
instrument was developed as a cooperative effort
between a student in a Master’s program and
faculty members at the University of the Pacific
Benerd School of Education and the Academy
for Academic Leadership. Participation by the
schools was entirely voluntary. The participants
responded to approximately ten questions via
electronic survey and attached relevant course
documents.
Responses were collected and
analyzed qualitatively, with telephone follow-up
in those cases where data collection required
it (clarification of responses by the principal
investigator).
The work was undertaken as a pilot study to
promote collaboration and communication
about best practices in dental ethics instruction at
California dental schools.
3. Findings/Results
All the schools utilized a lecture format to deliver
content in Dental Ethics courses. Small group
exercises were also used by these institutions.
Among the schools a variety of approaches to
learning activities are employed: group projects,
flipped classrooms (a teaching method that
delivers course content outside the classroom)
with prep assignment, daily reflections, online
materials, an American College of Dentists video
course (with completion certificate required),
panel discussions and American Society of
Dental Ethics projects and readings. Students
receive lectures on the CDA Code of Ethics and
the Dental Practice Act. Other methods used for
student engagement were lunch and learn, and
course electives focusing on professionalism and
ethics. Content was delivered at a variety of times
across doctoral programs, with courses specifically
designated as “Dental Ethics” or “Dental Ethics and
Jurisprudence” at two of the schools. One school
seeks to “demonstrate the highest quality of care,
governed by ethical principles, integrity, honesty
and compassion.” It performs assessments in this
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domain “through solving ethical dilemmas in
group discussions and applying principles in a
clinical setting.” It extends ethical discussions from
the classroom to the clinical setting via efforts to
“demonstrate collaboration with clients and with
other health professionals to develop a plan of
care to achieve patients’ positive health outcomes.”
Another institution has designed courses in ethics
specifically for orthodontic residents as well as
international dental students. Faculty mentioned
that ethics was mentioned in the classroom and
clinical scenarios across all years of their programs.
For example, a Systems Based Healthcare course
presented opportunities for dental students in
their third year of training to interface with other
healthcare providers in a venue where “topics
include team building, conflict resolution, sexuality
and healthcare law, healthcare delivery and
reimbursement, quality improvement, economic
and cultural considerations in healthcare decisions,
and public and personal perspectives of what
constitutes conflict of interest.” Other areas in
which learning sessions take place are lectures on
topics such as “Ethical Issues in Research” nested
within a “Critical Thinking and Lifelong Learning”
class. Malpractice and misconduct issues are
specifically discussed at all of the institutions. Small
group case discussions with written summaries
are used, and oral summaries are given “as called
upon in large group discussion.” One school
invites a guest lecturer from the California Dental
Board to speak to its students. Another presents
students with a panel discussion of California
Dental Association member dentists who have
struggled with alcohol and drug addiction issues in
conjunction with disciplinary actions by the Board.
In addition, an attorney experienced in legal ethics
regularly attends small group seminars, helping
to promote discussion in topics ranging from
informed consent, documentation, and contracts
to challenging clinical scenarios faced by studen ts
in their patient care.
Competence assessments in dental ethics are met
in a number of ways. Course directors employ
multiple choice exams, written exams, reflection
papers on ethical issues in clinic, case analysis, and
a video project. Students also use a live theater
presentation at one of the schools to demonstrate
their understanding. Other methods of assessment
include periodic quizzes, dentalethics.org modules
and discussions of classroom activities.
Because of the attempts of faculty across
disciplines to include ethics instruction in their
courses it can be difficult to estimate the number
of hours devoted to the subject in total. However,
available estimates range from twenty to over forty
hours of dedicated clock hours to formal ethics
instruction at the schools surveyed.
The professional backgrounds of the course
directors and faculty members charged with
teaching the subject are varied. The group
of faculty at the schools includes a variety of
individuals: a hygienist with an Ed.D., experienced
Stomatology Edu Journal
general dentists, psychologists, a general dentist
with a Master’s degree in ethics, a dentist self-
taught in ethics, Associate Deans from Academic
Programs, Student Affairs, Clinical Dental Sciences,
and the Student Clinic Director. Some of the faculty
members have formal ethics training and some do
not. Several of the faculty members belong to the
American Society of Dental Ethics, while others are
not members.
Collaboration with other departments or schools
at the respective institutions occurs in a number of
ways to deliver course content. While one of the
programs is in the midst of revision with its second
and third year courses, all faculty reflect the spirit
of collaboration in their curricula, with a range
from “not much, some in the past,” to guided
collaborations with Schools of Medicine and
Nursing. Another institution anticipates classroom
collaboration with students from its dental hygiene
program. Faculty also derive inspiration from
ASDA through its materials and methods, and
course notes at meetings of the American College
of Dentists. Course directors also employ online
coursework for their own education in Ethics.
In response to a query concerning ethical issues
faced by students, a number of topics surfaced.
One instructor felt that the “challenges are
largely the same as the ones we faced years ago.
The big difference is that technology magnifies
the opportunities.” Others mentioned that the
competition for grades and patient needs vs.
clinical requirements factor into the challenges
students manage during their education. “The
majority of students are aware of what is right to
do, but a few make bad decisions when faced with
a challenge that threatens their grades or ability to
graduate on time.” One faculty member dedicated
a book chapter to precisely this subject. Another
stated that “there have been several JDE (Journal
of Dental Education) articles on this topic that
accurately identify ethical challenges in predoctoral
dental clinic.” At one institution students are asked
to reflect upon the notion that clinic requirements
serve as a proxy for money during their training,
on the premise that financial issues will arise after
graduation. In terms of ethical challenges faced
by students, another faculty member stated that
“patient needs vs. clinical requirements is the big
one.”
Faculty members also face challenges in teaching
their courses. Two themes emerged from the
research: 1) Eliciting participation from mainstream
faculty members, and 2) intrinsic lack of student
interest in the subject. “We need more time and
resources (trained faculty) to do smaller group
case based learning, especially…after students
have had clinical experience.”
Another mentioned that instructors are challenged
by “carving out sufficient time to deliver content in
a very dense curriculum” and “keeping students
engaged by balancing the philosophy with real
life situations.” Faculty members make a concerted
effort to actively engage students in their
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