By Charles N. Bertolami, DDS, DMedSc Dean, University of California at San Francisco School of Dentistry

In an April 2004 essay in the Journal of Dental Education entitled "Why Our Ethics Curricula Don't Work," Dr. Bertolami argued that ethics curricula in dental schools must be considered failures because no one's behavior changes as a result of what is taught. The essay identified three specific weakness in a traditional ethics curriculum: 1)failure to recognize that more education is not the answer to everything; 2) ethics is boring; and 3) course content is qualitatively inadequate because it does not foster an introspective basis for true behavioral change. As a solution, the author proposed the implementation very early in the dental education program of a "precurriculum," which would address the disconnect between knowledge and action, using as an example the elective program he introduced at UCSF. In the following article, Dr. Bertolami revisits these issues.

To say that ethics curricula in dental schools must be considered failures may be overstating the case — though, admittedly — I was trying to be provocative. Maybe a more accurate assertion would be that our existing ethics curricula leave the job unfinished because students are unprepared to study professional ethics. I don’t see much effort in ethics curricula to remediate students in critically important ways —hence the notion of a precurriculum.

In the professions, there is often an implicit presumption of ethical behavior just because one is intelligent and successful. But the ethics of an applicant to dental school are seldom actually taken into consideration as part of the admissions decision. Students are usually accepted into dental school because of their intelligence, personality, test scores or service activities (often undertaken specifically with the ulterior aim in mind of enhancing their application to dental school). None of these things reveals a person’s ethics. Thus, I think it would be fair to assume that the ethical profile of dental students (and dentists) is pretty much the same as that of the general public. Even if this assumption isn’t technically true, I think we’re safer not giving ourselves the benefit of the doubt.

I made this point in my essay by asserting that we in the professions are almost trained to be bad; that is, professional people can be uniquely vulnerable — unintentionally trained to be unethical: “People who go to dental, medical, law school, etc., are accustomed to competing to get what they want. Competition means winners and losers. Professionals are at the top of a highly competitive pyramid and have become acclimated to (or even acquired a taste for) being the winner. Professionals such as dentists are equally accustomed to seeing a lot of losers along the way, and become hardened to the notion that there are always going to be losers.”¹

The central motive behind thoughtful introspection is simply that we really can’t be trusted with ourselves, without constantly questioning whether we might be giving ourselves (and the profession) the benefit of the doubt. An ethical life doesn’t just happen “…it takes education and practice in order to become virtuous.”²

Sommerville³ offers an arresting example of introspection envisaged from two completely different worldviews which appear superficially to yield identical immediate results, but for very different reasons and with significantly different implications: He asks students to

But your train of thought could have been quite different. You might have put yourself in her shoes and thought how unpleasant being mugged would be. Others might be depending on her, and the suffering you cause would spread even further. In short, you are taking others into consideration and wanting the best for them… . An ethics system based on honor is a self-regarding ethic, while one based in charity is an other-regarding ethic.

Sommerville’s point is that both ethical systems “are equally self-evident to those who grow up with them. But think of the corollaries. With honor goes a concentration on pride rather than humility, dominance rather than service, courage rather than peaceableness, glory rather than modesty, loyalty rather than respect for all, generosity to one’s friends rather than equality.”⁴

Today we admit students to dental school who are raised in and comfortable with both of these alternative worldviews (and many others besides). I don’t see our ethics curricula taking this foundational difference into account.

Incidentally, the “honor” scenario involving no one being around to see what someone is actually doing might be especially significant in a dental context inasmuch as what dentists do in a patient’s mouth in a private office is largely unobserved, creating a very different and a very potent dynamic in comparison with other kinds of healthcare givers whose professional lives are played out more in the open — physicians in a hospital setting for example.

An Introspective Precurriculum Versus a Traditional Ethics Curriculum

The premise of the precurriculum is that there is a disconnect between theory and practice that might be corrected if students experienced a remedial program aimed at making subsequent formal courses in ethics both more intelligible and more relevant. As a pre-curriculum, the course would come sometime before the standard ethics program but would still be part of the dental school’s overall educational program.

The precurriculum seeks to bring into the open some of the unstated, even subliminal, boundary conditions that underlie practitioner (and student) behaviors. Many different styles to achieve that aim would work, but I do think that uncovering such issues is important if subsequent courses in ethics are going to “take.”

In the context of professional education, I suggest that we use the term curriculum to mean a course or sequence of courses that, when viewed as a whole, satisfactorily answer three basic questions: What, how and why? Used this way, most dental schools don’t actually have an ethics curriculum. Most do a reasonable job at answering “what,” a less good job at answering “how,” and a poor job of answering “why.” In my essay, “Why Our Ethics Curricula Don’t Work,” I make the point that we see ourselves teaching about ethics, which is slightly different from teaching ethics — in the sense of expecting behavior to change as a result of what is taught. This happens because we set for ourselves the very limited objective of simply teaching students “what” and nothing more.

The question “what” is directed toward transmitting information — “what” in the sense of what is being taught? In other words, what is the formal course content, the actual subject matter, the product of research or accumulated experience, the repository of information considered important for students to know by those who are expert in the field?

Taking an ethics curriculum to the next level requires that we also ask: “how” and “why?” How do you actually do it in practice? This aspect of an ethics curriculum is not going to be achieved in any one didactic course because the “how” element can be accomplished only by role-modeling. In dental schools, we teach students how to be dentists; but unfortunately, that’s not what students learn. What students actually learn is how to go to dental school, which is entirely different.

Astonishingly little role-modeling takes place in dental school. It is quite possible for a student to go through four years of dental school and never actually see a dentist practicing dentistry. This is one of the great tragedies of traditional dental education. Are there isolated exceptions? Possibly. Community-based dental programs where students and practitioners treat patients side-by-side might be one such exception. But, in general, there are relatively few opportunities for students to see how a practicing dentist actually brings together the theoretical and highly compartmentalized procedural aspects of dental school to effectively care for significant numbers of patients (not just two per day) and, at the same time, makes a living at it — ethically. Usually, the disparate and compartmentalized components of dental practice all come together in only one place: the student’s imagination — often with significant assembly errors along the way. In other words, we teach students how to do dentistry; we don’t teach them how to practice it.

Role-modeling is the way to make this change because it answers the question “how?” How are things actually done in practicing this profession, how does it all really come together to work? Within the context of both teaching ethics and practicing dentistry, it answers the second of the three questions, “how?”

What, exactly, is role-modeling? I’d like to propose a definition: Role-modeling is a condition occurring in the mind of a student that conflates a given action with the identity of another person, a mentor whom the student respects, admires and — ideally — feels affection toward. Expressed more simply, the student says, “This is how Dr. X would do things, and I want to be just like Dr. X.” I’ve written elsewhere on possible adaptations of the dental curriculum to promote a greater degree of role-modeling.⁵

This leaves us with the question “why?” Answering the “why” question is the purpose of the precurriculum. Why? Why be good? Why be ethical? Only the answers to those questions have any hope of convincing anyone to do anything differently.

Ethical behavior requires people to act — and, often, to do so in the face of opposing social and personal pressures. Thus, the precurriculum is focused on the thought–action axis, helping a student to become sufficiently convinced of something that it alters behavior here and now. If consistently ethical behavior emerges from discovering satisfying answers to the three fundamental questions mentioned earlier (what? how? why?), topics in the precurriculum focus on helping students to formulate for themselves answers to the “why” question that are both objectively convincing and subjectively captivating as a basis for ethical behavior and the engine that translates good intentions into action. The answer to “why” has to emerge as a core insight that’s percussive enough to make a person do things differently.

In conducting my course at UCSF, I like to start with the question of “ultimacy.” That is, what does a student really care about ultimately? We play an exercise called “the 5 whys” which I describe in my essay and which I’ve borrowed from the business literature⁶ as a means of helping students define for themselves what is really of ultimate importance to them. Next we ask how well their current behavior moves them toward what they say they really want.

The course also introduces students to Goleman’s⁷ description of someone possessing emotional intelligence as being “socially poised, outgoing and cheerful, not prone to fearfulness or worried rumination. [Having] a capacity for commitment to people or causes, for taking responsibility, for having an ethical outlook, sympathetic and caring in their relationships, comfortable with themselves, others and the social universe they live in.” Almost everyone says that they would like to be such a person themselves and that they would be willing to work to become such an individual. We then begin to dissect this description of emotional intelligence and often conclude that emotional intelligence can be virtually equated to character (or at least to the fundamental traits that underlie character). We explore the attributes of character and discover that, in essence, character (and integrity) are driven not by intellectual or physical traits but by emotional ones. For many students this comes as a significant insight.

The Goals of the Precurriculum

I think that there is an enormous difference between simply doing the right thing and wanting to do the right thing. This nuance recalls T.S. Eliot’s observation that “[t]he last temptation is the greatest treason: to do the right thing for the wrong reason.” Aligning actions and reasons is a goal of the precurriculum. Very often I have found that there is a huge disparity between what students say they want and where their current actions are leading them. Rationally, I’d like to think that if students could be formally encouraged to think through what they actually want (not what they have been told to want by others), and then have their behavior assessed in light of their stated goals, the improved alignment would be beneficial both for them and for the profession.

Another goal is to motivate students to develop a genuine sense of enlightened self-interest. The key word is enlightened. A major problem is the inability of dental students to make the transition from learning about dental practice acts, codes of ethics and various historical ethical theories to acting based on what has been learned. When students (and practitioners) get into trouble ethically or even legally, it’s because they have simply misconstrued where their own true interests lie. I also believe that a goal of a curriculum devoted to introspective ethics is to set in motion a whole-life project devoted to both the process and the benefit of building character and the kinds of thinking necessarily antecedent to ethical decision making. I model this part of the course on Barbara Fredrickson’s “Broaden and Build” hypothesis.⁸

But does it work? How can you objectively demonstrate an improvement in ethics? What kind of outcome measures would suffice? Here’s a true story: In 1980, a UCSF dental student hijacked an American Airlines jet to Cuba. Since that time, there have been many changes made in the school. Correspondingly, no more dental students have hijacked airplanes. Are the changes and the lack of hijackings related? Do no hijackings in 26 years qualify as an outcome measure? No. In other words, I don’t think that we’re looking for that kind of evidence. We’re not trying to prove that some intervention can be credited with a 50% decrease in the number of dental schools making headlines because of cheating scandals. Rather, we’re engaged in a very low-cost enterprise that has intrinsic value—like someone who enjoys working in the garden and who never expects the weeding to actually ever be finished. We don’t try to objectively prove that a concerto is beautiful because we all realize that “music is more than vibrations in air.”⁹ To paraphrase Cornelius Plantinga, in teaching ethics, we are ennobled by the transcendence of our object.¹⁰ And that should be sufficient.

A Final Note

I am not on a campaign to have this particular idea adopted in exactly the way I have developed it. My point is simply to recognize that many dental students have not yet thought through for themselves some key life issues that relate very closely to ethics in professional life. In that sense, I don’t think they’re ready to experience our traditional ethics courses because we can make no assumptions about the set of boundary values that today’s students bring to the table. Thus, I think some sort of remediation is helpful. I’m hopeful that these opinions will open a conversation about how to make our ethics courses intelligible and of consequence. I’ve taken one particular approach to the matter, but there are undoubtedly innumerable other ways the same goals could be accomplished. The bottom line is simply this: It’s not about “statistical abstractions or points on a scatter diagram . . . [What’s] inside is what we, as fellow humans, are really after.”¹¹

"Recently a patient who came for a consultation told me a disturbing story. She and five or six friends discovered that they all shared the same dentist, who had told each person that she needed two, three, or four crowns. They came away with the impression that the dentist was more interested in the income he could bring in by making crowns than in each individual person’s treatment. Because I tend to be very conservative, I told the patient I felt she needed one crown at most. With all the excellent new techniques and materials available, it isn’t necessary to crown teeth right away. I think that proposing unnecessary treatment diminishes us all as health professionals."