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Eur J Dent Educ 2007; 11: 6474 2007 The Author.

Journal Compilation 2007 Blackwell Munksgaard


All rights reserved european journal of

Dental Education
Commentary

On ethics in the profession of dentistry and dental


education*
D. A. Nash
W.R. Willard Professor of Dental Education and Professor of Pediatric Dentistry, College of Dentistry,
University of Kentucky, Lexington, USA.

Accepted for publication 22 February 2007

and the historical notion of what it means to be a


Introduction profession will be considered. Contrasts will be drawn

P rofessional education in dentistry exists to


educate good dentists, dentists equipped and
committed to helping society gain the benefits of oral
between dentistry as profession and dentistry as a
business. A professional ethics for dentistry will then
be advanced. The essay will conclude with sugges-
health. In achieving this intention, dental educators tions as to what goals are reasonable for teaching
acknowledge that student dentists must acquire the professional ethics in dentistry.
complex knowledge base and the sophisticated
perceptual-motor skills of dentistry. The graduation
of knowledgeable and skilled clinicians in dentistry
is a necessary, but not sufficient, condition for
Defining ethics
ensuring quality oral health care. The further The distinguished French philosopher Francois Marie
requirement is the commitment of graduates to Arouet, Voltaire, wisely observed, If you wish to
applying their abilities with integrity, that is, provi- converse with me [first] define your terms (1). Ethics
ding quality care in their patients interest. Ulti- is a branch of the intellectual and academic discipline
mately, good dentistry depends on individuals of philosophy. Philosophy literally means love of
committed to treating society and their patients wisdom (2). Philosophy is pondering, wondering,
fairly, that is, ethically. Thus the justification for reflecting, questioning, reasoning and speculating
teaching professional ethics in dentistry is to facili- about life. The contemporary philosopher, Mortimer
tate the personal and professional development of Adler, expressed its relevance: Philosophy is every-
aspiring dentists into socially and professionally bodys business. The human being is endowed with
responsible human beings. the proclivity to philosophize (3).
This article will discuss ethics in the broad context Ethics is that branch of the discipline of philosophy
of life, and seek to apply the concepts of ethics to the that studies morality. It is the science of the moral
profession of dentistry and to teaching ethics in dental (4). Ethics is intellectual reflection on issues of
education. In doing so, it will define ethics and morality. Morality is about behaviour how humans
differentiate it from two related but different concepts, relate to one another. Moral behaviours are those
religion and law. Ethics will be explained in both the actions that can be evaluated as good or right using
sense of lifes aspirations and lifes obligations, and an reasoned, objective criteria. The distinction between
argument advanced for why one should be ethical. In ethics and morality is the distinction between the
seeking to understand ethics in the profession of object of study morality and the study itself
dentistry, the concept of profession will be defined, ethics. Ethics seeks to answer the questions of: How
should I live my life? How should I behave? Therefore,
ethics is about goodness and badness, right and
*Presented at the 32nd annual meeting of the Association for Dental
Education in Europe, Krakow, Poland, 31 August 2006. wrong, virtue and vice, oughts and ought nots, and

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Commentary

ends and means. Ethics raises two major questions: understanding ethics as a human endeavour rather
What is the good life? that is, what should I value; than a uniquely religious one (8). His argument
what is important; what matters; what is meaningful; follows: God commands us to do right, then: 1) the
what is worthwhile. These questions are generally actions are right because God commands them, or 2)
considered the ethics of aspiration. The second God commands them because they are right. If 1)
major question of ethics is What is right? that is, from a moral perspective, Gods commands are
what duty do I have to others; what is good and arbitrary and the doctrine of the goodness of God
virtuous behaviour? These questions are considered is meaningless. If 2) one must admit a standard of
the ethics of obligation. Before considering these right and wrong independent of God. From a
questions in the context of life and dentistry, it is religious perspective, it is undesirable to regard
important to distinguish ethics from two closely Gods commands as arbitrary, or to give up on the
related notions law and religion. goodness of God. Therefore, Aquinas concluded, a
standard or right and wrong independent of God
must be accepted. Ethics is about the basic moral
standards inherent in the structure of social living,
Differentiating ethics from law and incumbent on all human beings regardless of the
religion presence or absence of any religious convictions.
Laws are made by society as binding rules of conduct
on individuals in societys belief that obeying such
rules of conduct are imperatives for the society to
function in a fair manner. Conceptually, laws are an
Ethics of aspiration
attempt to ensure that the relationships among indi- Many have written about what constitutes the good
viduals in society, as well as the appropriation of life. The ethics of aspiration will be considered briefly,
societys resources, are fair, that is, just. Justice is the primarily to add a needed balance in subsequently
basic and foundational principle of ethics. It is considering the ethics of obligation. To what should
important to acknowledge two issues in distinguish- human aspire? Only Aristotles ancient answer will be
ing ethics and law. First, society does not deal with all considered. He said, eudomania; literally meaning to
issues of morality by legislation, only those moral have a good spirit, which is traditionally translated
issues that have a significant impact on societal into English as happiness, or well being. Aristotle
functioning. Thus while it is morally wrong for went on to describe a life of eudomania (happiness)
one to fail to keep a promise to a friend; in general, as a complete life, lived in accordance with virtue
failing to do so does violate a law. Second, laws are and attended by a moderate supply of external goods
temporary consensus always to be critiqued (and (9).
revised) by referencing the ethical principle of justice. For Aristotle, the happiness of ones life could not
All legislation is to be understood as an attempt to be assessed at a point in time as life is unfolding, but
create a perfectly just or fair society; such a society as only as one nears lifes end in reflection. A happy
Plato attempted to describe in his ancient classic, The life, for Aristotle, was to be distinguished from day-
Republic (5). to-day joy or contentment. He believed that it could
Religion literally means a reconnecting or reu- not be said one had lived a happy life if ones life
niting; a binding together. The etymology of the was cut short by premature death. One needs to have
word is the Latin re again, and ligare to bind or lived a complete life, a life lasting long enough to
connect (6). Thus religion is a reconnecting; an experience the many and varied aspects of life (with
attempt at overcoming the estrangement or separ- resulting development of understanding and wis-
ation humanity feels from God (in supernatural dom) that only comes from living to a normal life
religions) or from Nature (in naturalistic religions). expectancy.
Plato, in the Euthyphro, has his spokesman, Socrates, The second element of Aristotles description of a
raise a question that has become one of the profound happy life was one lived in accordance with virtue.
questions in intellectual history: Is conduct right The ancient Greeks understood virtues to be those
because the gods command it, or do the gods characteristics of an individuals personality (charac-
command it because it is right? (7). Approximately ter) that enables an individual to fulfil the function of
1600 years later, the Christian theologian/philoso- being human. For Aristotle this meant rationally
pher, Thomas Aquinas, attempted to answer the control ones behaviour by abiding the rules of
question, and in so doing helped set the stage for morality, and realizing ones full human potential.

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Commentary

Aristotle understood those virtues (characteristics)


Ethics of obligation
that contribute to a life of happiness to exist as a
mean, for him, a golden mean between qualities he What duties does one owe to ones fellow beings in
judged as excesses and qualities of deficiency. Thus order to live in a civil society where it is possible for all
courage, the strength to venture, is in the mean to realise their aspirations for the good or happy life.
between cowardice (excess fear) and rashness Aristotle reminds us that Man is by nature a political
(deficient fear). He also emphasised the virtues of animal (11). His use of the word political is synony-
liberality being generous (existing in the mean mous with our word social. We are not hermits. By
between frugality and prodigality), temperance self- nature we live in groups, cooperating with one
restraint (existing in the mean between abstinence and another to survive. Humans are social beings.
gluttony), and pride self-respect (existing in the Morality, that discipline that relates us to our world
mean between self-deprecation and arrogance). Cer- and to other individuals in our world, evolved when
tainly courage, liberality, temperance and self-respect our early hominid ancestors came to understand that
are all personal qualities considered important to rules were necessary for social living (1214). Rules
living a life of excellence and therefore, for Aristotle, of cooperation among members of our species were
a life of happiness. Socrates said, Virtues are condi- imperatives for survival in a hostile world. Biological
tions for personal success within a social fabric (5). evolution has created in homo sapiens the capacity for
However, Aristotle also believed the truly unique empathy the ability to understand anothers position
function of a human being was that of rationality, the and perspective and based on empathy, to develop a
ability to self-consciously reflect on ones life and its sense of fairness and a capacity for conflict resolution,
direction; and to make thoughtful decisions based on the essential requisites of a system of morality. Francis
knowledge and experience. This led him to conclude Hutcheson and David Hume, English philosophers,
that the intellect is the noblest part of human nature. writing before Charles Darwin, understood that hu-
Therefore, to truly fulfil the function of being human mans are endowed with what they called a moral
of being virtuous; one must cultivate ones intellec- sense that is innate an evolved constituent of our
tuality continually growing and developing intel- nature as humans (15, 16).
lectually through learning. He said, All men by In the 17th century, the English philosopher Thomas
nature desire to know (10). We are learning beings, Hobbes considered what life would be like in a state
and continued learning is a key element of human of nature. He imagined a state where there were no
happiness. He expressed it: acknowledged rules of morality, no laws, no police, no
If happiness consists of virtuous activity, it must be courts and no government. In such a circumstance he
the activity of the highest virtue, or in other words, of said there would be an equality of need, scarcity of
the best part of our natureWe conclude then that resources, essential equality of human power, and all
happiness reaches as far as the power of thought does, would be self-interested attempting to survive. The
and that the greater a persons power of thought, the conclusion of his analysis constitutes a famous sen-
greater will be his happiness, not as something tence in intellectual history. He said that such a state
accidental, but in virtue of his thinking, for that is would result in a constant state of war, of one with
noble itself. Hence happiness must be a form of allwhere life is solitary, poor, nasty, brutish, and
contemplation (9). short (17).
The third and final ingredient of Aristotles under- Cooperation is essential to escape this state of
standing of happiness is: attended by a moderate nature and to live in an ordered society, one that is
supply of external goods. Aristotle did not believe safe, stable, predictable, where each person can pursue
one had to be wealthy to have a happy life. However, the realisation of their potential their lifes goals and
he also did not believe one could live in poverty and aspirations. Morality, and the so-called moral rules,
achieve a happy existence a moderate supply of are the basis for such cooperation. Morality is funda-
resources are essential to happiness. mentally about rules of cooperation among humans.
Throughout intellectual history there have been Gert has offered a defense of 10 basic moral rules:
many thoughts on that to which a human should do not cheat, do not cause pain, do not disable, do not
aspire. Most all acknowledge the importance of the deceive, do not deprive of freedom or opportunity, do
difficult-to-define notion of happiness. However, not not deprive of pleasure, do not kill, do not break your
an insignificant number of contemporary thinkers promises, obey the law, do your duty (18, 19). His ten
believe little of substance has been added to the moral rules can be summarised as dont cause others
subject since Aristotles thinking. evil or harm. Moral rules, such as these, are rules that

66
Commentary

no rational person would want violated with regard to and violate the moral rule, do not deceive, or tell
themselves, or anyone for whom they cared without the truth revealing the hiding place of the Frank
reason. Moral rules protect individuals from suffering family and violate the moral rule, do not deprive of
evil or harm at the hands of another. The English freedom or opportunity. The moral life is ambiguous
philosopher John Locke expressed it: The law of and frequently requires thoughtful reflection and
naturewhich obliges everyone, and reason which is justification for the choices made. Immanuel Kant,
law, teaches all mankind who will but consult it, that the 19th century German philosopher, helps further
being all equal and independent, no one ought to characterise moral justification with his famous
harm another in his life, health, or liberty of posses- dictum, the categorical imperative: Act only on
sions (20). that maxim that you would will it as a universal
Our duty, to gain the benefits of an ordered society, law (21).
requires that we set aside short-term self-interested The moral rules that identify our duties to others
inclinations in favour of general rules that impartially correspond to individual rights: I have a right to
promote the welfare of everyone, including ourselves honesty, therefore you have a duty not to deceive me; I
ultimately. We can do this because others in society have a right to fairness, therefore you have a duty not
have agreed to do the same thing as it is in their to cheat me; I have a right to freedom, therefore you
ultimate self-interest as well. Thus, we have the have a duty not to restrict my freedom; I have a right
so-called social contract; an implied contract that to life, therefore you have a duty not to kill me; I have
permits us to escape the state of nature with its a right to possessions, therefore you have a duty not to
anarchy, and create an ordered society. steal from me. And, you have all of the same rights,
Ethics is a fairly blunt instrument. It is not a therefore I have all the comparable duties.
scalpel that cuts sharply, enabling one to definitively In the 16th century, B.C.E., in response to the
separate good from harm, and therefore right from question: Is there a single word that one could
wrong. Although precise and rigorous, ethical analysis practice throughout life? Confucius responded: Reci-
does not enable one to determine that in every procity do not inflict on others what you yourself
situation there is only one action that is moral. While would not wish done to you (22). Plato, in the 4th
certain alternatives may be ruled out, not infrequently century, B.C.E., put it this way: May I do to others as I
a range of actions exist that are morally acceptable. would that they should do to me (23). Jesus of
Sometimes situations are so complex that all possible Nazareth in the first century phrased it: Whatsoever
actions infringe on one moral rule or another. It is a you would that men should do to you, do you even so
matter of determining which actions would result in to them (24). John Rawls, the late Harvard University
the least amount of harm or the greatest degree of philosophy professor, in his widely influential book, A
good; which moral rule deserves receiving the greater Theory of Justice, stated that this obligation of recipro-
weight in decision-making. city is basic to the concept of justice. When a
All of this is to suggest that moral rules are to be number of persons engage in a mutually advanta-
understood as universal, but not absolute (18). Moral geous cooperative venture according to rules, and thus
absolutism is the claim that a moral rule should restrict their liberty in ways necessary to yield advan-
never be violated for any reason. Universality means tages for all, those who have submitted to these rules
that the moral rules are to be followed by all rational have a right to similar acquiescence on the part of
human beings, regardless of their religion, culture, those who have benefited from their submission (25).
ethnicity or nationality. Everyone is always to obey This orientation to social living is referred to as the
the moral rules except when rational, impartial ethics of reciprocity.
people advocate that a violation be allowed by It becomes obvious as to why individuals should be
anyone in a comparable situation (19). It is possible moral. If we do not live by these rules of social
that the absolute adherence to a moral rule could cooperation, treating others fairly, we cannot expect
result in more harm that good and morality is others to keep the rules with regard to us. If we make a
about avoiding harm and promoting good. As has habit of doing harm to others, others will not be
been suggested, all of the options available in a reluctant to do harm to us. This acknowledgment of
situation could result in violating a moral rule. the value to ourselves of abiding by these moral rules
Consider the following constructed example: Nazi of the social contract is traditionally referred to as
storm troopers are at the door of the Dutch business enlightened self-interest.
were Anne Frank and her family are hiding in the Ethics is about how to live. As a discipline within
upstairs quarters. Does one lie to the storm troopers, the field of philosophy it concerns itself with the good

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Commentary

life that to which one should aspire. However, it also over the lives of others. This power makes those
concerns itself with how one relates to others, the they serve vulnerable. To be in a fiduciary relation-
moral obligations one incurs by living in society. At its ship means to stand in a special relationship of trust,
core, ethics is about rules of cooperation. As cooper- confidence or responsibility to another. Professionals
ation, it focuses on the idea of treating others fairly, as must be able to be trusted that they will always
one would want to be treated by others. Morality has place the welfare of those they serve above their
evolved as a result of the evolution of a moral sense own personal interests or agenda. Historically, pro-
in homo sapiens; a moral sense that was necessary for fessionals have professed (promised/vowed) a
cooperation among our hominid ancestors in order to competency based on advanced learning for which
survive. Ethics is ultimately about justice, that is, they will be morally accountable in placing this
fairness in the social contract; fairness in both our expertise in service to society. The concept of
individual relationships and fairness in the distribu- profession is deeply rooted in the notion of making
tion of societal resources. a promise to society and to individual members
thereof (28).

Defining profession
The concept of profession, as employed historically by
Differentiating a profession from
sociologists, must be distinguished from some uses of
a business
the term in contemporary usage. It is common to The concept of profession has strong cultural over-
designate as a professional anyone who is skilful at tones. Culture is the collective mutually shaping
what they do, is not an amateur in doing it, and is paid patterns of norms, values, assumptions, beliefs, stand-
for their work. Thus we have professional sports stars, ards, and attitudes that guide the behaviour of
professional artists and actors, and professional individuals and groups, whether those groups be
mechanics. Classically, sociologists have understood families, religions, races, geographic regions, nations,
the traditional learned professions as law, medicine businesses, or professions (2931). Norms are what
(including dentistry as a specialty thereof) and the the culture understands as normal; that which should
clergy. Unique and common characteristics of these occur naturally; the cultures guiding rules or princi-
three groups have been identified as their work is ples. Values are what the culture desires; desires
primarily intellectual; their work is based in science and create purpose; purpose provides meaning. Assump-
learning; their work is practical, their work can be tions are what the culture takes for granted; what it
taught and learned through education beyond the usual presupposes. Beliefs are those notions in which the
level; they are organised into democratic collegial units; culture places its trust and confidence. Standards are
and they exist to achieve societally defined goals rather the uniform referents of the culture; the touchstones
than the self interest of their members (26). used in measuring and evaluating. Attitudes are the
These learned professionals have traditionally been emotional intentions of the culture, what it feels and
assigned extraordinary moral duties based on the wills.
power differential existent between the individual To describe differences among cultures is not
professional and the person served. The Dutch philo- necessarily to draw moral conclusions or judgements;
sopher, Baruch Spinoza, affirmed: Knowledge is only to characterise differences. Of course, one can
power (27). Professionals hold power over those they prefer one culture over another. Preferences are not
serve; power based on the knowledge gained through necessarily moral statements. There are differences
advanced study and learning. They know when their between the culture of France and that of Spain;
client, patient, or parishioner does not. The attorney between the culture of Europeans and Americans;
holds power over property/possessions, through the between the culture of Jews and Muslims; between the
ability to draft legally binding documents; the physi- culture of a predominately socialist country and a
cian (dentist) holds power over personhood, through predominately capitalist one. And, to the point in this
the ability to prevent pathology, heal disease, and/or discussion, there is a difference between the culture of
alleviate suffering; the clergyman holds power over a profession and the culture of a business.
providence, though presumed knowledge of Gods Based on the concept of profession, the culture of
will and expectations. dentistry can be described (32). The norm of dentistry
Learned professionals are in a fiduciary relation- is that oral health is a primary good; an end in itself.
ship with others because of the power they have The values of dentistry are care and concern for all

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Commentary

people and their oral health. The assumption of to Thrasymachus: But tell me, your physician [den-
dentistry is societal good. The belief of dentistry is tist] in the precise sense of whom you were just
that cooperation and reciprocity with society can speaking, is he a moneymaker, an earner of fees or a
result in good for all. The standard for dentistry is healer of the sick? And remember to speak of the
justice/fairness in all dealings with patients and physician [dentist] who really is suchCan we deny
society. The attitude of dentistry is egalitarianism. then, said I, that neither does any physician [dentist],
Dentistry has historically understood itself to be a insofar as he is a physician [dentist], enjoin the
profession, to have the culture of a profession, and advantage of the physician [dentist] but that of the
thus has laid claim to professional privileges. patient (5).
Understanding dentistry and its culture as a pro- Finally, in contrasting the nature of dentistry as a
fession is in tension with understanding dentistry and profession vs. dentistry as a business, it is necessary to
its culture as a business. Yet many dentists today seem draw a distinction between social and consumable
to be adopting the culture of business. In the culture of goods, a distinction drawn by the intellectual father of
business, the norm of dentistry is that oral health is a market economics, the Scotsman, Adam Smith. In his
means to a private end, that of the dentist, with 1776 work, An Inquiry into the Nature and Cause of the
patients being a means to that end. The values of Wealth of Nations, Smith argued for such a distinction
dentistry in the culture of business are entrepreneur- (35). He affirmed that there are basic social goods
ial; building a successful enterprise profits. The upon which the free market for consumable goods is
assumption of dentistry as a business is that the dependent. The marketplace cannot function absent
private, personal good is to be maximised. The belief safe, secure, healthy, informed customers. Ensuring
system of dentistry as a business is dentistry is a such should not be considered commodities of the
component of the free enterprise system. The standard marketplace. Basic oral health care is, or should be, a
of dentistry as a business is the marketplace. The social good comparable in nature to police protection,
attitude of dentistry is social Darwinism. public safety, fire protection, public education, and
The late Talcott Parsons, of Harvard University, basic general health care. Basic oral health care is not,
considered to have been the dean of American or should not be, a consumable product of the market-
sociologists, defined a profession by contrasting pro- place similar in nature to purchasing furniture, elec-
fessions with businesses. The core criterion of a full tronics, sporting equipment, travel or entertainment.
fledged profession is that it must have means of The practice of dentistry is, or should be, the
ensuring that its competencies are put to socially practice of a profession. Dentistry is only a business
responsible usesprofessionals are not capitalists, in the sense that good business practices must exist in
and they are certainly not independent proprietors support professional practice.
or members of proprietary groups (33).
Traditionally, dentistry as a profession has focused
on serving the oral health needs of patients and
society, with the financial gain derived from such
Professional ethics in dentistry
being a natural and appropriate consequence of the Professional ethics in dentistry is based in the moral
service provided. Today, increasing numbers of den- rule previously advanced, do your duty. Ethics in
tists understand themselves to be practicing in the dentistry derives from the role dentists assume in
marketplace of health care, competing for patients, agreeing to enter into a relationship with society.
treating patients with the primary motivation of In this relationship, dentists profess/vow/promise to
earning a significant profit for their services. In short, do good for society by employing their knowledge
operating within the culture of a business. and skills in the pursuit of oral health for all. Doing
Rashi Fein, the distinguished health economist, ones duty now requires the promoting of good, not
expresses distress regarding the seeming transforma- just following the moral rules that help keep from
tions occurring: A new language has infected the causing harm. This raises the question of what
culture of health care. It is a language of the market- constitutes the moral duties of dentistry as a profes-
place, of the tradesman, and of the cost accountant. It is sion, and of individual members of the profession.
a language that depersonalises both patients and health In explicating the moral duties of dentistry and
professionals, and treats health care as just another dentists, it is necessary to return to the foundation of
commodity. It is a language that is dangerous (34). all ethics, that of justice. Rawls, in the previously
In the Republic, Plato presents a dialogue between referenced Theory of Justice, understands justice to exist
Thrasymachus and Socrates with Socrates responding in two senses. In both senses he understands justice as

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Commentary

fairness (25). Distributive justice, frequently referred of dentistry with society, creating the question of
to as social justice, deals with how the benefits and fairness in the relationship; an issue of justice of
burdens of a society are to be fairly distributed. In the ethics.
second sense, justice is a concern for the nature of
inter-personal relationships. What constitutes justice/
fairness in the relationship of the profession of
dentistry with society at large? What constitutes
Justice in the individual clinical
justice/fairness in the relationship of individual
encounter
dentists in their clinical encounters with patients? What does justice as fairness demand in the individual
dentist-patient encounter. What are the moral duties
of the dentist in caring for patients. Six such duties can
be delineated: beneficience, respect for autonomy, veracity,
Justice in the relationship of dentistry quality care, continued learning, fidelity (37).
with society The goal of the relationship in which one assumes
Rawls, in explicating the nature of justice, uses what the role of health professional and the other that of
has become a famous hypothetical. He asks one to patient is the benefiting of the patient. In the language
stand behind a veil of ignorance and envision a of professional ethics it is the principle of beneficience.
world into which one will be born; but not knowing In seeking the care of dentists, patients seek to gain the
into what circumstance he or she will be born, that is, benefits of oral health. Benefiting the patient by the
to a rich or poor family, intelligent or dull, male or dentist is accomplished by providing the highest
female, European or Asian. He argues that given such quality of care possible contingent on the professions
a condition, people will design a world with some current scientific understanding, the clinical circum-
degree of risk aversion. In such a rationally designed stance, and the patients desires. The Hippocratic Oath
world of self-interest the following three conditions states it: I will use treatment to help the sick according
would exist: 1) each person will have an equal right to to my ability and judgment, but I will never use it to
the most extensive system of liberties comparable with injure or harm them (38).
a system of equal liberties for all; 2) persons with In providing oral health care, clinicians acknowledge
similar skills and abilities will have equal access to there are frequently alternative therapies available in
offices and positions of society; and 3) social and providing a benefit, and that all have inherent risks or
economic institutions will be so arranged as to harms. In this regard, it is important to acknowledge
maximally benefit the worst off. This last condition that, philosophically, the professional fee required for
is the one most directly relevant in considering the care is a harm the patient must incur. Dentists have a
responsibility of dentistry to society. Rawls affirms duty to consider the alternative therapies available in
that in such a world, differences in status will providing quality care to a patient, and to weigh
ultimately result due to the range of differences potential benefits against potential harms or risks.
among individuals in native talent and ability. How- However, the dentists conception of potential benefits
ever, he states that while these resulting status vs. the harms may differ from the patients. Whose
differences may be unfortunate, they are not unfair. values should determine the ultimate course of action.
Given a Rawlsian view of justice as fairness, the This introduces a companion principle of professional
profession of dentistry as a social and economic ethics to beneficience, respect for autonomy. Autonomy
institution, and one granted a virtual monopoly to derives from the Greek and literally means self-rule or
practice by society, has an obligation to work for a self-governance. Humans are their own persons; the
health care scheme that permits the worst off in author of their own lives. The moral rule of do not
society to gain the benefits of oral health. To what deprive of freedom or opportunity means that it is
extent do the socially underprivileged in Europe morally correct to acknowledge and affirm the right of
have maximum access to the professions resources self-determination of patients.
in assisting them in gaining and maintaining the Caring for patients by providing them with oral
benefits of oral health. In the USA, the socially and health benefits while also affirming and respecting
economically disadvantaged have the worst oral their autonomy requires that a dentist gain a morally
health and the poorest access to care (36). Such is (and in most jurisdictions, a legally) valid informed
clearly an issue of social justice. A lack of definitive consent. Gaining an informed consent is the method
action on the part of societys disadvantaged calls by which dentists honour the commitment to benefit
into question the reciprocity of the profession patients while respecting their autonomy in doing so.

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Commentary

An informed consent has three requisites: adequate alcohol. Although it is possible for some adolescents to
information provided to a patient with adequate rationally consider identified problems and potential
understanding by the patient; consent is gained courses of therapy and thus provide a morally valid
without coercion; and the patient is competent to give informed consent; in most jurisdictions individuals
a rationally informed consent. below the age of eighteen cannot legally provide an
The adequate information a patient requires to informed consent. It should also be noted that anxiety
make an informed decision regarding their care reduces an individuals rational deliberating powers.
typically includes: the nature of the problem (diagno- It is not unusual for individuals seeking dental care to
sis); goals of treatment; alternatives in treatment; be in a heightened state of anxiety. It is important for
advantages and disadvantages of various alternatives; the dentist to recognise such and do whatever neces-
benefits and risks of alternatives; recommended treat- sary to reduce the patients anxiety in order that their
ment; prognosis; and professional fee required (cost). decisional capacity is not compromised. Gaining an
Adequate information/understanding does not informed consent permits the dentist to affirm and
require that the patient be told everything there is comply with both the professional ethical principles of
to know about the problem/treatment, but only beneficience and respect for the autonomy of the
the information adequate to make an informed decis- patient. However, there are additional principles of
ion; information that a reasonable person would professional ethics inherent in the dentistpatient
want to know (39). The reasonable person standard is relationship.
the basis for determining adequacy. The concept of In benefiting the patients, providing quality care
adequate information can deteriorate into a mechan- based on the professions current scientific evidence
ical rehearsal of data to legally protect the dentist and understanding is a prima facie duty of dentists.
unless tempered with the idea of patient comprehen- Quality in health care has been defined as the
sion. Comprehension is ensured by processing infor- degree to which health services for individuals and
mation reciprocally asking the patient to validate populations increase the likelihood of desired health
their understanding of the information provided (40). outcomes and are consistent with professional know-
Such reciprocal processing of information with pa- ledge (43). Professional standards of care in two
tients has been referred to as the deliberative model dimensions must be met. The therapy provided must
of the doctorpatient relationship (41). Gaining an be appropriate care for the specific problem being
informed consent is at its foundation a teaching/ addressed. And, when the appropriate treatment is
learning encounter, with the dentist being the teacher provided, it must be provided in a quality manner
and the patient the learner. Interestingly, this encoun- that is, meeting established technical standards for the
ter, more than any other in dentistry, emphasizes the treatment. For example, quality care is provided when
role of the dentist as a doctor. The etymological root of a cast crown is appropriately recommended for a
the word doctor is teacher (42). badly mutilated tooth, and when the cast crown is
The second ingredient of gaining an informed con- fabricated and placed in such a manner that it meets
sent is that it be accomplished without coercion. the professions recognised clinical criteria for a cast
Providing basic, accurate information is required, and crown. The rapidly changing knowledge base of the
persuasion is permissible. However, moving beyond profession changes occurring through advances in
persuasion by manipulating information to have the research forces the professional in dentistry to be a
patient pursue the course of therapy the dentist believes lifelong learner. One cannot provide quality care, care
most desirable is morally inappropriate. Manipulation, consistent with the professions knowledge base, if
by its nature, is deceptive and violates the moral rule one is not familiar with that knowledge base. Thus
do not deceive. Veracity, truthfulness, is a moral duty continued learning is a further professional moral duty
in all aspects of the dentist/patient relationship. for the dentist (44).
The final ingredient of an informed consent is Dentists have a professional duty to fidelity. Fidelity
competence. A patient must be able to rationally is faithfulness. As has been indicated, the root mean-
deliberate on the information being provided. Some ing of profession is to profess, to make a promise.
patients lack competence, or decisional capacity, and Inherent in the promise of the dentist to patients is to
therefore cannot consider the reasonableness of var- be there for them; to place their interests as primary; to
ious courses of action. Groups of individuals who may do for them the best that can be done with regard to
be unable to provide a valid informed consent include oral health, and to not abandon them in a time of their
those who are mentally ill, mentally disabled/retar- need. One noted bio-ethicist, acknowledging the vari-
ded, demented, or under the influence of drugs or ability and uncertainty of the individual biological

71
Commentary

response to therapy, has encouraged health profes- Appropriate goals for teaching professional ethics
sionals to never guarantee or promise a patient have been identified (46, 47).
anything, save fidelity. I will always be there with
you for you; no matter the outcome of therapy. I will To sensitise student dentists to the moral
not abandon you (45). dimensions of professional life and practice
Students should be assisted in learning/understand-
ing that human beings live in a complex matrix of
relationships, relationships that have potential for
Teaching professional ethics in dentistry good and bad consequences. Not infrequently, ethical
Some argue that the moral conscience is developed problems are embedded and unidentified in lifes
early in life, and if student dentists are not morally circumstances. Considering and evaluating situations
virtuous upon matriculation, instruction in ethics is arising in the practice of dentistry, in the context of
futile. Early moral education is an important deter- their potential for good and bad consequences, sensi-
minant of ones commitment to the moral life. Moral tises student dentists to the idea that there is a moral
virtue is the habit of making good and right choices. perspective. Professing dentistry as a lifes calling
Through repeated behaviours in the formative years, intensifies the moral dimension of life as patients seek
habits of action are developed, some supportive of relationships with dentists in order for dentists to
living the moral life, others potentially not. Intelligent positively do good for them with regard to their oral
reflection, with disciplined substitution of alternative health.
behaviours, is necessary to break bad habits and
replace them with good ones. To develop in student dentists skills of ethical
Education is a reflective experience that can lead to analysis
behavioural change. To suggest that education cannot Critically and reflectively considering alternative
alter behaviour, including behaviour with moral courses of action and their consequences requires the
consequences, is to adopt an intolerable cynicism cognitive tools of ethics. Skills of analysis must be
about education. No doubt the inherent virtue of developed in using the concepts, principles and rules
student dentists varies, with some finding it easier of ethics. Development and exercise of problem-
than others to do the good and right thing. While solving abilities in ethics has real practical value.
acknowledging variations among individuals, the Critical thinking in ethics assists student dentists as
intention of teaching professional ethics is to facilitate human beings and as health professionals in discrim-
all student dentists becoming good dentists. Teach- inating between good and bad consequences and
ing must work to dispel the idea that morality is therefore, right and wrong behaviour.
optional; that it is only for those wanting to be either
altruistic or religious; and to help student dentists To foster in student dentists respect for
understand that morality is essential to cooperation disagreement and toleration of ambiguity
among people living in a civil society, where each Although precise and rigorous, ethics does not neces-
person can achieve the greatest good and suffer the sarily enable one to determine that one and only one
least evil or harm. action is moral; sometimes choices must be made
While teaching professional ethics seeks to elicit a between conflicting goods, and other times choices
sense of moral obligation, changing behaviour directly made among alternatives all with potentially negative
is not the intention, as such could be considered consequences. Equally virtuous people may disagree
indoctrination. Rather, teaching professional ethics on courses of action. However, care must be taken to
should provide a framework for student dentists to ensure that the grounds for their disagreement are
sense and consider the moral obligations they incur in reasonable and logical. Dentists, as all humans, must
society, both as individuals and as dentists. Such learn to be tolerant of the views of others, to the extent
intelligent reflection can serve as a basis for determin- these views comport with human rationality. A goal of
ing whether or not changes are required in their moral teaching ethics is to enable student dentists to
habits and behaviour. Ultimately, the goal of teaching acknowledge that much of human life is ambiguous,
professional ethics is to encourage student dentists to and to learn to tolerate ambiguity. Tolerance for
develop and rely on a moral compass they have made ambiguity acknowledges that there are dimensions
their own; one that is based on sound principles of fair of existence in which no definitive behaviour is ideal
cooperation among human beings. or conclusive.

72
Commentary

student who aspires to become a dentist. While


To assist student dentists in explicating the moral
didactic instruction is necessary, it is not sufficient
responsibilities incurred in becoming a member
for the learning of professional ethics in dentistry.
of the profession of dentistry
Among the most powerful instruction existent in our
The relationship of the profession of dentistry with
faculties is that which is modelled by the behaviour of
society is best understood as a cooperative relation-
members of the faculty. As a consequence, ethical
ship with mutual benefits and burdens. The professing
behaviour, both in treating patients and treating
of dentistry as a lifes work is a promise to society to
students, must be modelled by all members of the
care for its oral health, and to bring the art and science
faculty. Classroom and clinic protocols must be
of the profession to bear in preventing and curing oral
established which promote basic concepts of morality,
disease. Basic to the complex relationship of care-
as well as promote and reinforce the specific principles
provider and cure-receiver is the good of both parties.
of ethics that relate to the practice of dentistry.
However, because the relationship is complex, cir-
cumstances emerge in which harms can occur. Teach-
ing professional ethics should seek to explicate
concepts, principles and rules to be considered in Conclusion
forging cooperative relationships that ensure all
Among the most important learning that occurs in
parties obtain the greatest good possible in the
faculties of dentistry is that of learning to be a
relationship; and that all are treated fairly. Teaching
professional. While knowledge, perceptual-motor
should explore the terms of cooperation when patients
skills, and problem-solving abilities are basic to
seek the care of dentists in helping prevent or cure oral
becoming a dentist, and demand major time and
disease, as well as the terms of cooperation between
attention in our curricula, helping aspiring colleagues
the profession of dentistry and society in allocating the
learn to apply their newly developing skills with
resources of society to ensure all have access to a
integrity must be a fundamental concern. The profes-
decent, basic minimum of oral health care.
sion of dentistry is a profession because of its
commitment to serving the public in gaining the
To motivate student dentists continued learning
benefits of oral health. The caring behaviour of
in the field of professional ethics
previous generations of dentists, and their commit-
Authentic education is education that prepares for and
ment to ethical conduct, has earned the profession the
promotes further learning. A real and substantive goal
trust and confidence of society. If this professional
of teaching professional ethics in dentistry should be
relationship is to be sustained, each new generation of
develop in student dentists a positive attitude toward
dentists must come to understand the nature of a
the subject of professional ethics so that subsequent to
profession, and the ethical obligations incurred in
graduation they will seek opportunities to further their
becoming a member of the profession of dentistry.
knowledge and understanding of the subject, in the
context of their lifelong learning. As one educator has
quipped, a good education should leave much to be
desired. References
A variety of instructional methods are available and
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