By Frederick G. More, DDS
Professor of Epidemiology & Health Promotion
and of Pediatric Dentistry

I am usually ruffled when I hear the word “integrity.” Typically, the word is used in a way that suggests the speaker’s belief that everyone knows what integrity is, and that we all agree on its meaning. But do we all agree on what integrity means? Integrity is adherence to a set of values, which may or may not be widely held. Integrity among healthcare professionals denotes adherence to values of respect for individual autonomy, a commitment to act in the public’s best interest, avoidance of harm from all sources, truth telling, and equity and justice. But standing in front of a mirror, how many of us would honestly evaluate ourselves as strictly adhering to these values?

In 2004, Charles Bertolami, Dean of the University of California at San Francisco School of Dentistry, published an article in which he asserted that ethics curricula in dental schools accomplish nothing.¹ Some ethics teachers were indignant because they believe that ethics curricula have never been better. A second article, published months later, responded to his critics.² As I reflect on the two articles, I wonder if perhaps Dr. Bertolami had in mind a larger theme, one concerning the ethical standards and values within our profession —standards and values which mirror the crisis in ethics in the broader culture.

In his fascinating book, The Cheating Culture: Why More Americans Are Doing Wrong to Get Ahead (2004), David Callahan points out the general acceptance of cheating in our culture.³ He gives many examples, such as parents buying diagnoses of learning disability for their children to gain extra time on SATs and to become more competitive and attractive to top schools. He talks about healthcare professionals using procedure codes that do not represent actual diagnoses to get broader coverage from payers for their patients. He claims that Americans today have a dual moral compass, one relating to issues like property, sex and fidelity, and another that changes direction when it comes to issues of money, achievement and success. Extending this example, our mirror becomes two-faced and more — like circus mirrors that distort one’s image.

Dentists point with pride to the fact that the profession consistently ranks as one of the more trusted professions in society. This legacy of previous generations of dentists, who have earned their patients’ trust, is ours to lose. On the one hand, dentists across the U.S. strive to be the best dentists possible. They meet and exceed requirements for continuing education. They accept their responsibility as respected members of their community and contribute in many ways to the quality of life for everyone.

On the other hand, some dentists compromise their ethics by developing treatment plans that focus on financial gain for the dentist rather than a shared plan that benefits the patient. The respect they have earned in other contexts will be lost when the public catches on that many dentists do not do a head and neck cancer screening as part of their oral examination. The public may become skeptical when they learn that some dentists, while interested in helping at the time of a catastrophe, do not have current certification in basic life support, much less training in catastrophe preparedness. The public will continue to be justifiably outraged when newspapers, like The New York Times, report alleged Medicaid fraud by dentists.

Ethics courses do not teach ethics. Done properly, ethics courses provide a forum for open dialogue about the values, beliefs and responsibilities we share as healthcare professionals. Effective ethics courses stimulate dialogue that extends beyond the hours allocated for the formal ethics courses. Ethics courses must empower students to raise issues with their peers, faculty members, dental school administrators and — yes — even the deans of the college. But does this approach extend beyond the dentist’s formal education? While several dentists are prominent in their advocacy of ethical reflection and are excellent role models in their personal and professional lives, dentists do not elect to take courses in professional ethics.

Former Dean Michael Alfano was fond of saying that “Good people make Good dentists!” This simple statement has profound implications. What is a Good person and who decides? If you do not lie, cheat or steal, is that enough? Is a Good person required to be compassionate, empathic and accountable? If we look in the mirror, see our reflection and cry, “You are Good!” does that qualify us as Good? I believe Mike Alfano reflected a high-minded view that Good people are willing to be measured by their actions, beliefs and values. The key word is "measured.” A person of integrity is humble and open to receiving feedback and evaluation.

Integrity is in large part an “inside job.” How do we feel about our actions in the last 24 hours? If we apply Callahan’s moral compass, how true is the direction we choose? Do we resist the temptation to add an additional procedure to an insurance claim form to add to our reimbursement? Do we recognize that we have no right to the additional payment? Do we spend extra time with an anxious patient and skillfully manage the situation without receiving recognition or compensation for that time?

I am convinced that not even the best teacher can “teach” ethics. We can foster dialogue and raise issues concerning our actions and the actions of others, including our elected leaders, who obfuscate issues by taking ambiguous stands. We can take a higher road by admitting that we do not know the answer to every question, and we can conduct research to find evidence to support our position. And then we can look in the mirror and be honest about what we see. Maybe the mirror really is the ultimate test of integrity.