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Teaching and learning ethics

PAPER

Towards a specic approach to education in dental ethics: a proposal for organising the topics of biomedical ethics for dental education
Sek Gorkey, Tolga Guven, Gurkan Sert
Department of Medical Ethics and History of Medicine, Marmara University Faculty of Medicine, Istanbul, Turkey Correspondence to Dr Tolga Guven, Marmara Universitesi Tip Fakultesi, Haydarpasa Kampusu Deontoloji AD, Tibbiye cad. No.49, 34668 Uskudar Istanbul, Turkey; tolgaguven@hotmail.com Received 29 June 2011 Accepted 7 July 2011 Published Online First 2 September 2011

ABSTRACT Understanding dental ethics as a eld separate from its much better known counterpart, medical ethics, is a relatively new, but necessary approach in bioethics. This need is particularly felt in dental education and establishing a curriculum specically for dental ethics is a challenging task. Although certain topics such as informed consent and patient rights can be considered to be of equal importance in both elds, a number of ethical issues in dental practice are only remotelydif at alldrelevant for medical practice. Therefore, any sound approach to education in dental ethics has to recognise the unique aspects of dental practice in order to meet the needs of dental students and prepare them for the ethical challenges they may face during their professional practice. With this goal in mind, this paper examines the approach of the authors to dental ethics education and proposes a system to organise the topics of biomedical ethics for dental education. While the authors perspective is based on their experience in Turkey, the proposed system of classication is not a rigid one; it is open to interpretation in other contexts with different social, cultural and professional expectations. Therefore, the paper also aims to inspire discussion on the development of an ideal dental ethics curriculum at an international level.

INTRODUCTION
Dental ethics as a specic eld of study is hardly as popular as medical ethics. As noted by Ozar, this discipline can be considered as a young eld, although a heightened awareness of ethical issues has been observed to have changed the approach to dental ethics education from the late 1970s in the USA.1 This situation is probably related to a practical need for managing ethical issues: dentists today are facing challenging ethical problems to an unprecedented degree.2 A similar observation has also been made by other authors, who have indicated that published reports have shown concern about several ethically problematic practices such as .poor quality of care, violations of public trust, agrant advertising..3 While awareness of ethical issues in healthcare may have triggered similar responses in other parts of the world, such developments generally are recent. For instance, in Turkey, such awareness has been observed much more recently, starting in the 1990s, particularly after the enactment of the Regulation on Patient Rights in 1998.4 While compulsory medical
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ethics lectures began as early as the 19th century during the pre-Republic era,5 contemporary concepts such as patient autonomy have begun to be debated only very recently in Turkey. However, a dramatic change in the approach to education in dental ethics in Turkey is yet to be seen. There is no department of dental ethics in any university in the country. At best, this means that lectures on dental ethics are usually provideddif at alldby the members of the faculty of medicine. However, the majority of these lecturers are likely to have a background in medical, rather than dental ethics. While medical and dental practice share common features, certain topics in biomedical ethics are only remotely related to dental practice, whereas some other topics specic to dental practice may have little relevance for medical doctors. Therefore, dental ethics lectures can be a signicant challenge for those who are not familiar with the unique aspects of dental practice. Conversely, if the lecturer does not or cannot adapt the content of the lectures to these aspects, it will not be realistic to expect such general lectures to meet the needs of dentistry students. The department of medical ethics and history of medicine of the Marmara University Faculty of Medicine has been facing this challenge for 16 years.6 During this period, the department has developed a system for creating a curriculum specic to lectures on dental ethics and a short section summarising this approach was recently published in a separate thematic article in the Bulletin of the International Dental Ethics and Law Societyan open-access, non-peer reviewed publication.7 In a nutshell, this system aims to classify the issues in biomedical ethics and put them in an order of signicance relevant for dental practice. This approach has the advantage of allowing the lecturer to arrange a specic curriculum for dental ethics, as well as avoiding an overload of theoretical information. This paper aims to explain our approach in detail and open it to international academic debate, with the hope of making a practical contribution to the eld of dental ethics. It should be noted that the three authors have different backgrounds (dentistry, medicine and law, respectively), each with a postgraduate degree in healthcare ethics. This heterogeneous composition of the team allows the assignment of lectures on curricular topics in accordance with faculty members academic background and expertise. The authors believe this signicantly contributes to the efciency of their approach.
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Teaching and learning ethics

MEDICAL VERSUS DENTAL ETHICS: THE NEED FOR A SPECIFIC CURRICULUM
While dental ethics can easily be considered as a specic branch within biomedical ethics, the medical ethics approach still appears to be the dominant perspective in this eld. It is not uncommon to see the terms medical ethics and biomedical ethics/bioethics being used interchangeably, without any implied difference. This is not surprising, because many of the contemporary concepts and debates in biomedical ethics have their roots in the patientephysician relationship. However, there are some topics in dental practice which may not be relevant for physicians or other healthcare professionals. By the same token, some of the key topics in medical ethics, such as the debates on euthanasia, abortion and assisted reproduction procedures, are only remotelydif at alldrelated to dental practice. Obviously, these common and different aspects need to be taken into consideration if a more specic approach to dental ethics is to be developed and taught. With this aim in mind, we suggest that topics in biomedical ethics can be reorganised in three main and two intermediate groups from the perspective of dental ethics, as shown in table 1. and dentistry, although case-based examples from medical practice may need to be adopted for dental practice, particularly for lectures on informed consent and patient rights. The legal aspects of the topics in group B are also wellestablished and students frequently wish to learn about their legal responsibilities, particularly in lectures on informed consent and patient rights. Therefore, the legal framework governing these issues is also summarised in the lectures. However, this may be a challenging task for ethicists who do not have a background in law, especially in countries like Turkey, where there are no departments of health law or medical law and legal issues in healthcare are frequently addressed by referring to general principles and provisions in law owing to the inadequate number of specic laws governing the provision of healthcare services. The authors believe that the advantage of having lecturers with different backgrounds in a department becomes particularly evident at this point. This heterogeneous composition not only facilitates a multidisciplinary approach to bioethics, but also helps greatly in assuring the accuracy of information provided in the lectures.

Group AB
Topics in this column are not entirely specic to medical practice; they are considered to have some relevance for dentistry as well. Therefore, a separate category between groups A and B was created for their classication. The most signicant topic in this section is probably ethics in oncology. While the treatment of cancerous lesions of the oral cavity may not be a part of the routine oral healthcare service of the dental practitioner, the ethical aspects of cancer-related information may nevertheless be important in dental care for a number of reasons. Cancers of other systems may be suspected during or after dental interventions. In addition, dentists may frequently have patients who are receiving treatment for cancers outside the oral cavity. In all these circumstances, the dental practitioner would at least be expected to know the potential ethical issues regarding cancer-related information. Therefore, common ethical problems in oncology (including ethical dilemmas related to truth-telling and the right not to know ) are covered in detail in these lectures. It should be noted that in the near future, at least two of the topics in group A (organ transplantation and genetics) may also need to be classied under group AB, depending on the advances that may be made in the dental sciences.

Group A
The topics in the rst column are highly specic to medical practice and unlikely to be encountered by dentists. We suggest that providing only basic knowledge on these issues to dentistry students is appropriate and detailed lectures may be only marginally useful. Lectures on these topics aim to serve as an introduction to the eld and provide general information about the scope and content of the issues examined in biomedical ethics. It could be argued that these topics could be omitted from a dental ethics course; the so called life and death decisions are usually not a part of dental practice. However, as healthcare professionals, dentists may also serve in different positions within the healthcare system. They may become administrators in a healthcare facility, may serve as members on a hospital ethics committee and/or in other structures involved in shaping healthcare policies. In all these circumstances, a basic understanding of the ethical arguments about the beginning and the end of life, the denition of death and allocation of healthcare resources will be necessary. Furthermore, even if dentists do not assume such responsibilities in the future, they still need to know the functions and compositions of the aforementioned committees, as well as when and how to consult them. Therefore, we think that introducing dentistry students to these concepts is important.

Group C
This group of topics is considered to be entirely specic to dental practice and lectures in this group are provided only in the school of dentistry. The lecture on dental intervention for aesthetic purposes builds on the foundation laid in the introductory lecture (see column BC in table 1 and the paragraph describing the column BC below), but it focuses more on the practical aspects of this concept, such as the ethical concerns

Group B
Topics in this group are considered to be equally important for dental and medical practice. We think that the content of lectures on these topics need not differ in schools of medicine Table 1

A system for classication of issues in biomedical ethics from a dental ethics perspective
Overlapping issues of medical and dental ethics AB Less signicant for dental practice Ethics in oncology B Equally signicant for medical and dental practice Informed consent Ethical issues in biomedical research with human volunteers Research ethics committees Hospital ethics committees Patient rights BC More signicant for dental practice Introduction to the concept of aesthetics Ethical aspects of advertising Ethical issues in HIV infection and AIDS Issues specic to dental ethics C Dental interventions for aesthetic purposes Orthodontics and ethics Ethical and legal aspects of dentistedental technician relationship

Issues specic to medical ethics A Euthanasia Abortion Assisted reproduction Genetic technology Organ transplantation

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Teaching and learning ethics

regarding the abuse of aesthetic dentistry. The problems related to the commercialisation and promotion of self-interest in dental practice8 are also addressed. Furthermore, Turkish law recognises the interventions of aesthetic dentistry within the scope of the work contract,4 which, unlike other interventions, requires the healthcare professionals to guarantee the result of the treatment beforehand. Therefore, the students are also provided with information about the implications of this legal concept and the legal liability that may be associated with aesthetic dentistry. Interventions in orthodontics also have a unique nature. The treatment may take a very long time and the patient is frequently a minor who may not be able to consent to the procedures. Therefore, the success of these interventions heavily relies on the quality of the communication and cooperation in the patientefamilyedentist triad; if the dentist is not aware of the potential ethical issues in this context, problems may arise. For this reason, the third topic in group C is dedicated to the examination of the ethical aspects of orthodontics. The lecture is basically built upon the concepts dened in the informed consent lecture. Additionally, the concepts of assent,9 as well as other ethical and legal requirements regarding the integration of minors in decision-making10 are covered. The nal topic of the column is a complex one that involves the dentistedental technician relationship. The interaction between these two professionals plays a signicant role in dental care services. However, to our knowledge, the ethical aspects of this relationship are rarely dealt with in the literature. Furthermore, while the legal aspects of this relationship have been clearly dened in Turkish legislation,11 the authors experiences suggest that students are usually unaware of them. Therefore, the lecture on this topic rst focuses on the legal requirements that have been outlined in the relevant regulation. Afterwards, potential ethical issues that may be observed during the dentistedental technician relationship are examined. The lecture emphasises that the patients may be unaware of the existence of a third party (the technician) who is involved in certain dental services and the implications of this from the perspective of informed consent and patient condentiality are discussed. Additionally, certain ethical problems are also examined from the perspective of the dental technician and questions such as whether the dental technician has the right to know the patients seropositivity (as in infections such as hepatitis and HIV) are examined. It should be noted that interactions with other professionals, such as dental hygienists, are also signicant and specic to dental practice and can also be classied under this column. However, these professionals do not occupy a signicant place in Turkey s oral healthcare and therefore are ignored in the lectures. Generally, private practice has occupied a signicant place in dental care services and Turkey is no exception. Private practice has strong commercial implications, because modern dentistry heavily relies on hi-tech equipment and materials, which can be expensive. Unlike the private ofce of a family doctor, a private dental practice can be demanding nancially, which may inevitably force dentists to run private ofces or clinics like businesses, focusing heavily on nancial concerns. Unfortunately, the inherent commercial nature of such a practice can easily cause dentists to forget their ethical responsibilities as healthcare professionals. Some authors have expressed their concern on this issue, indicating the possible tendency in dentistry to focus solely on personal/nancial gain.8 Therefore, it is important to warn dental students about this dual nature of private practice and help them realise the potential ethical problems that may arise. Such ethical issues become particularly evident in advertising, which is a wellknown aspect of any commercial enterprise and also very common in private dental practice.12 13 Hence, the possible problems that may arise in advertising activities of dentists have always been emphasised in medical deontology texts in Turkey.14 The lectures on this topic aim to point out these problems to students, as well as to inform them about the relevant legal provisions governing advertising. The third topic in this column, ethical issues in HIV/AIDS, is very different from the previous two. Nevertheless, owing to the interventional nature of dental procedures, HIV infection and ethical issues related to HIV/AIDS have important implications for dental practice2 and are, therefore, also included in column BC. The lectures on the topic examine the ethical basis of the duty of the healthcare professionals to treat HIV-seropositive individuals, as well as the ethical problems that may be related to social stigmatisation of these individuals in healthcare services. Other concerns, including those related to patient condentiality, the so called duty to warn third parties and the routine use of HIV screening tests are also addressed.

LIMITATIONS AND CONCLUSIONS

Since the approach presented in this paper is based on the authors teaching experience in the local context (Turkey), the applicability of this approach in settings with different social, cultural and professional aspects needs to be questioned. We acknowledge that this issue can be a shortcoming of any approach based on local experience. However, while the differences in question will certainly have an inuence on the content of a curriculum, the approach itself can still be useful in different settings. For this reason, we designed our classication to be a exible one that provides guidance ondrather than specically prescribesdthe topics that should be covered in ethics lectures in dental education. The table presented in the earlier section of the paper should be understood as the reection of the authors current needs in their teaching experience and these needs are certainly shaped by the local context. Therefore, neither the placement nor the names of these topics are etched in stone and they can change depending on the needs of the educators and students. As already noted in the paragraphs addressing the content of column A, such changes can be due to the advances in technology, but also due to a number of other factors such as the country s own professional environment, as well as its social and legal developments. A typical example of this is the absence of dental hygienists in Turkey. In any other country where this profession exists, the ethical aspects of their professional relationship with dentists (which would preferably be classied under column C) would have to be addressed in the lectures.
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Group BC
Topics in column BC are strongly related to dental practice, although they are not specic to dentistry. For instance, aesthetics may also play a role in medical practice (as in the case of plastic surgery), but is less signicant than in dentistry, where aesthetic concerns are a prevalent factor in decision-making.2 However, this introductory lecture does not cover an in-depth discussion of aesthetics. Rather, it aims to provide guidance on how to approach aesthetics and connects ethics and aesthetics by emphasising the value-laden nature of aesthetic judgements. Once the students realise how subjective aesthetic judgements can be, it becomes easier for them to understand why the patients own aesthetic expectations (and not simply the dentists opinion) should be a part of the decision-making.
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Teaching and learning ethics

Anotherdand perhaps more strikingdexample of this could be given on the topic of end of life care. This is a poorly addressed issue both at the theoretical and practical level in Turkey: The legal limits of the right to refuse treatment are problematic, there are no specic guidelines on the issue, instruments such as advance directives are not in use15 and professional institutions (such as hospices) focusing on end of life care in the country do not exist.16 While this situation may be expected to change soon, it would not yet be realistic to say that dentists play an important role in end-of-life care services in Turkey. Therefore, we do not specically address this topic in our lectures; at best, we could include it under column A. Instead, we provide basic information on the general concept of euthanasia, which we choose to classify under column A. Depending on the national, professional and social contexts, other educators can easily include such topics under some other column (probably under column AB) and focus on these topics as they see t. On the other hand, certain problems, such as those arising from the commercial nature of dental practice or the ethical aspects of interventions for aesthetic purposes, will probably be equally signicant for manydif not alldeducators. Last but not least, we should note that our proposal is just one perspective for organising the topics in biomedical ethics for dental education; it should be understood as an option among many other possible approaches to this task. Furthermore, although the practical aspects of our approach have been this paper s primary focus, we also aimed to point out the need for a specic approach to the issue and stimulate debate on it at the international academic level. Considering the current status of dental ethics as an academic discipline in comparison to medical ethics, we believe the paper will have served its purpose if it succeeds only in this latter aim.
Acknowledgements We thank Professor Ray Guillery for reviewing the grammar and the style of an earlier draft of this article. Funding This article was supported by Marmara Universitys Scientic Research Projects Commission (BAPKOdBilimsel Arastrma Projeleri Komisyonu). The project code is SAG-D-310510-0181. Competing interests None. Contributors The authors conrm that all authors included on this paper full the criteria of authorship and that there is no one else who fulls the criteria but has not been included as an author. Provenance and peer review Not commissioned; externally peer reviewed.

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Towards a specific approach to education in dental ethics: a proposal for organising the topics of biomedical ethics for dental education
Sefik Gorkey, Tolga Guven and Gurkan Sert J Med Ethics 2012 38: 60-63 originally published online September 2, 2011

doi: 10.1136/medethics-2011-100067

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