Report #4, Q3 2015


Included in this report is progress from the summer of 2015 through the convocation in Washington, DC. Attention during this period was focused on publishing the first of the empirical studies, selecting the states to participate in visits, and validating an omnibus value survey instrument.


Dentist and Patient Views on Ethics

A characteristic we are copying from the Flexner and Gies studies is to make our report fact-based. There is a lot to be learned by listening to what the participants in oral health have to say about their experiences and what might be done better. A major set of activities in the project will be conducting a range of “experiments.” These will be published, where suitable, in the literature and in the Journal of the American College of Dentists. Eventually, they will be amalgamated into a final, book-length report.

The first of these studies was published in issue #2 of the 2015 Journal of the American College of Dentists under the title “Do patients and dentists see ethics the same way?” It is available at or

Ninety-one dentists and 54 patients worked through eight ethics cases on topics such as informed consent, charity care, and disagreements over billing. Respondents rated how likely they were to pursue each of several courses of action and they reported the importance of various reasons for their actions.

On some issues, such as hostile workplace environment (technically a legal matter), there was nearly perfect agreement between dentists and patients. In other cases there was uncertainty. Perhaps the most unsettled area was the extent to which dentists are responsible for engaging colleagues when cases of gross and continuous faulty treatment is clearly detected. Patients overwhelmingly assume that the profession is policing itself. Dentists are evenly split among looking the other way and becoming involved. This is one of several areas where dentists and patients are not on the same page and where dentists are divided from their colleagues on what to do.

Two other findings point to areas to be explored. First, there was virtually no connection between actions and reasons. If this holds up, we will have to rethink our approach to teaching ethics based on first learning and then applying principals. Second, the basic structure of values seems to be different for dentists and patients. Dentists placed more emphasis in the eight cases studied on technical excellence and paternalism; patients were more interested in oral health outcomes and professionals engaging their colleagues.

The eight cases are being converted to video format for online viewing. The norms of actions and reasons for dentists and patients are being attached to the cases online so dentists can use these cases for continuing study and get feedback as one would in a seminar setting.


Face-to-face Input

Both Flexner in medicine and Gies in dentistry visited all school in the United States and Canada in preparation for their reports. It will not be possible to follow this model and do a detailed national study. Further, on investigation, it appears that many of the activities associated with practice take place at the state level. This includes licensure, scope of practice, standards of care, discipline, and peer interactions. Accordingly, it has been decided to gather direct information from a representative group of states. So far, four states have been identified and have given approval in principle. These include California, Ohio, Oklahoma, and North Carolina. Visits will be made to the states over the next eighteen months. Observations and open-ended interviews will be conducted with state officers, dentists, and patients.

Further, one organization – a dental school – has agreed to participate in a project to determine whether the general ethical climate in a group can be elevated. One of the hypotheses that is beginning to emerge is that good people placed in bad situations will struggle to be ethical and that progress can be made by building stronger moral communities. The plan for this work will follow the model of the Malcolm Baldrige National Quality Award which is a self-study program to promote excellence rather than an audit to find fault.


National Values Survey

One aspect of the overall project that will have national participation is a values survey. It is reasonable that where choice is available, people will follow their values. An internationally standardized survey called the Moral Factors Questionnaire will serve as the basis for this survey. The generic MFQ is available online and has been described in Jonathan Haidt’s book The Righteous Mind. I have received permission from the authors of the MFQ to modify it for use with dentists and patients. The past few months have been devoted to psychometric validation of the instrument, a process that involves adjusting the wording of items based on feedback from individuals taking the survey. The survey instrument is just about ready for use.


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