Vol. 104 No. 4 October 2007

EDITORIAL

Dental students cheating—how can that be?

Several well-publicized incidents involving dental stu-dent dishonesty have occurred over the past year. Un-derstandably, individuals at the particular institutionsand in the dental profession as a whole were dismayed.Leaders at those schools conducted investigations, de-cided what penalty those who cheated should receive,and made operational changes to try to prevent futureoccurrences. This was neither pleasant nor particularlysurprising.

However, what is disturbing is the cascade of otherreactions to these events. Dentists, often in the com-munities where the problems surfaced, began second-guessing the decisions made by school leaders, usuallyproclaiming the punishments were too lenient and al-leging the decision sent the wrong message to otherstudents. Those sentiments were even expressed in aneditorial in this Journal. Many cried that these eventswere scandals that arose because of inattention to eth-ical training in the schools and differences in the ethicalstandards of the current generation of students (moreabout this later). Some blamed societal pressures formaking dishonesty more likely to occur or even toler-ated to some extent.

Hearings and conferences were quickly organized.Ethical “experts” and other interested parties heard thedetails of the various incidents and offered their opin-ions. The deans of dental schools had repeated meet-ings to look for ways to fix the problem, state dentalsocieties were told by invited speakers that there is anethical crisis in dental education, and articles appearedin various publications with advice to schools on howto train people to be honest.

Granted, there is always room for improvement invirtually everything humans do. In my experience, mostdental schools have had elaborate, formalized programsin ethics and professionalism as part of their curricu-lums for a number of years. Many include courses inethical decision making that touch all 4 years. Theyinclude general and dental-specific cases involving eth-

ical dilemmas. The American Dental Association and

American College of Dentists often assist in providingthese courses. Some schools go on to demonstrate thehigh priority they place on ethical behavior by conduct-ing solemnization events during which students reciteand/or sign an honesty pledge or honor code. In addi-tion, many schools include students as part of, or as theprincipals in, honor or ethic councils. These selectedindividuals then set codes of conduct and adjudicateallegations of dishonesty among students. Virtually allschools include some assessment of honesty in theiradmissions process. Maybe more is needed or perhaps,as addressed by Charles Bertolami,1 dean at New YorkUniversity, in his excellent essay on this topic, there ismore wrong causing ethical problems in dentistry thanthe lack of proper education during dental school.

There are 4 reasons why the various reactions to thisseries of incidents are so perplexing. First, is howindividuals can so harshly criticize the decisions ofothers when they did not have access to all of theinformation used to make decisions involving punish-ments, or imply that they have never been dishonestthemselves. Second, is why so many seem convinceddishonesty in dental education is a new phenomenon orsomehow worse than ever before, in spite of having nosound evidence that this is true. Third, is the implica-tion that ethical lapses are more prevalent among dentalstudents than practicing dentists or that ethical prob-lems in the dental profession are the result of someinadequacy in the education of dentists. Fourth, andmost concerning, are the regular statements being madethat the current generation has some kind of glitch intheir ethics circuitry.

There is a proverb having something to do with rocksand glass houses. Also, one of the key things I havelearned as a leader is to reserve judgment, and partic-ularly criticism, until I have heard all sides to an issueand learned important details about the situation. So, isit fair to be concerned about dishonesty in dental edu-cation? Certainly! However, to conclude that such in-

cidents and their outcome were the result of an uncaring

447

OOOOE448 Editorial October 2007

or cavalier attitude toward ethics among dental educa-tors is patently wrong.

I hope those who are ready to educate the deans ofthose schools with the highly publicized cheating inci-dents on how they should have handled their schoolswill return the favor and let those deans into theirpractices to critique how they run their organizations,including what personal expenses they write off asbusiness expenses or what trips in the name of continu-ing education they took that look suspiciously likevacations. Constructive criticism should always be wel-come. But until you can walk in another’s shoes, suchcriticism should be couched in terms that recognize thatsomeone without all the facts can rarely fully compre-hend the factors swaying the decision maker’s ultimatedeterminations.

What about the claim that there has been some majorup-tick in the amount of unethical conduct in schoolsand colleges of dentistry? I began dental school in 1973and have since been involved in dental education as atrainee or educator, save for 3 years I spent in medicine.In every circumstance there were some incidents thatrepresented some form of dishonesty among students. Ihave discussed the theory that there is a greater prev-alence of cheating in dental education than ever beforewith other dental deans, and I have yet to find one whoagrees with this theory. This is interesting, because, asa group, dental deans tend to be more senior membersof our profession and, for the most part, have spent allof their careers working with dental students. Of coursethis is not proof that dishonesty among dental studentsis not on the rise, but it is strong evidence to counterthose who claim that ethical breaches among dentaltrainees are increasing.

A correlate to the notion that unethical behavioramong dental students is more common in the mostrecent decade or so is that those who graduated beforethat time and are now practicing dentistry are, in gen-eral, more ethical. In addition, some fear that theclaimed increase in dishonesty portends increases inunethical behavior in dental practice once these stu-dents graduate. The logical reaction to these hypothesesis that it is dental education’s fault that some studentsare dishonest or, at the least, dental schools have failedto properly train students in how to be honest.

I have been involved in education since I was 4 yearsold as either a registered student or in dental education,or in several years as both, in a large variety of insti-tutions and professions. I have 2 relevant observationsfrom those experiences. First, in every one of thosecircumstances I observed dishonesty in one form oranother. Second, for most of my education any discus-sion of ethics or honesty was absent. The only formal

ethics course occurred in law school, where all students

took a required course in the ethical practice of law. Mybusiness school education occurred in the late 1990sand did have some case materials on the ethics of thecorporation and leaders as part of the coursework inleadership. However, I believe most dentists who wentto dental school before the 1990s had little or no ethicaltraining during dental school or other aspects of theirdental education. Many of them, like me, learned thedifference between honesty and dishonesty from theirparents and other family members, religious leaders,organizations such as the Boy and Girl Scouts, fromreading books or other media sources, and even fromtheir friends and peers. (One might ask, Hupp have youever done something dishonest? I plead the 5th if thatanswers your question.)

As a dental educator who covers in our studentclinic, in my present and past positions, I have had thechance to see dental work that patients have received bycommunity dentists. Most of it is excellent, but a trou-bling amount of the work is substandard and someborders on negligent. Some of the problematic workrepresents improper treatment such as new crowns onperiodontally unsound teeth or poorly done endodontictreatments. I also read the newsletters or visit the Websites of state dental boards, with their long lists ofdentists who were found to have done improper orillegal acts. In both instances I suspect these are only asmall sampling of actual incidences of unethical prac-tice. I also see problems among faculty practice patientswho have received care from dentists consideredamong the best in a community. In addition to substan-dard clinical care, there are other ethical lapses such asintentionally upcoding procedures, overselling certainprocedures, using untested techniques or materials onpatients without their knowledge, or refusing (in overtor subtle ways) care for patients on the basis of theirrace or other characteristics. This is in addition to moreunder-the-radar forms of questionable ethics mentionedearlier related to gaming the tax system or what shouldbe given credit for meeting continuing education re-quirements.

Comparing what I see in dental education to what Iobserve in the practicing community, I feel neitherarena has a monopoly on honesty, or is trending in oneor the other direction on the honest-o-meter. But Iadmit I may be wrong.

Well, if there is this constant low drone of unethicalbehavior in the dental profession, is it perhaps the faultof dental education institutions?

This idea may have some credence. Formalized eth-ical training in dental education is relatively new and,as previously mentioned, there are regular examples ofunethical behavior among practicing dentists. (Note: I

consider all licensed dentists to be practicing dentists

OOOOEVolume 104, Number 4 Editorial 449

whether in private practice, academic dentistry, work-ing for corporations, or in other careers in which theywork under their dental license.) So a direct relation-ship seems to exist. However, to complete this virtualexperiment one now needs to track the ethics of thosein practice who did receive some formal ethics educa-tion while a dental student. Perhaps some social scien-tist will carry this out for us and let us know a decadeor so down the road. I suspect we will not see anydifference, but perhaps that’s too cynical a view. Yet,my own school has a robust program in ethics andprofessionalism that I support and help grow. We try tokeep it relevant to our students and interactive. Do Isupport this because I’m convinced it will work? Frommy previous remarks the answer is clearly no. But I dofeel there is intellectual value in helping students learntactics to use when they face ethical dilemmas duringtheir lives. So if they choose to be honest and ethical*(which I hope they do), they will have the tools neces-sary to reach decisions in a logical manner. Dentalschools can also establish codes of conduct to clearlyset forth expected behavior, at least of how studentsshould conduct themselves while a student or resident.

But as Bertolami purports, is it reasonable to thinkteaching ethics in dental schools can actually changebehavior? I too wonder if it is naïve for anyone to thinkthey can alter a 20-plus year old’s moral compass in theclassroom. When faced with a decision to cheat or notto cheat in dental school or in one’s dental career, willthe individual pour through his or her ethics courseclass notes or try to remember what some professor saidwhen deciding what to do in that situation? I presumethose susceptible to being tempted to be dishonest gothrough a mental calculus weighing the value receivedfrom being unethical against the likelihood of beingcaught and the resulting penalty. Of course, schools andcolleges of dentistry should design systems to detectcheating among students and prospectively set forthmeaningful penalties that are likely to deter those proneto dishonesty. Student involvement in the creation ofthe ethical code and monitoring of ethical behavior andadjudication of ethical breaches can also be used to givestudents a real stake in the endeavor to take to heartbeing ethical in all aspects of life. Peer pressure andencouragement do work. This, in many ways, is the

*The words “honest” and “ethical” have similar meanings but “eth-ical” carries more of a feeling of acting in a moral way and definitionsoften have being ethical as abiding by a defined code of conduct orset of standards. An example of how these concepts could differwould be a statement in a code of conduct stating that ethical conductincludes the obligation to report unethical or dishonest behavior, evenif one is not participating in such behavior. In this case failure to doso would be considered unethical even though few would view this as

being dishonest.

same process used by the dental profession as a wholeto attempt to influence the ethics of its members.

However, if a school adopts a view that studentsshould own the ethics program of a dental school, whatabout those who claim the current generation of stu-dents have a flawed sense of what is ethical or honest?If this is true, allowing students any significant role insetting or enforcing ethical conduct would be like let-ting tobacco companies compose the warning labels oncigarette packs. The rationale used to support the theorythat there are generational differences in ethical stan-dards is flimsy at best. Those holding this belief point toour youth growing up in an era of corporate and gov-ernment scandals; celebrity inappropriate behavior; andmusic, television, and Internet messages that glorifysociety’s bad actors. They also claim that pressurescreated by high tuition, competition for desirable dentalresidency positions, and the need to satisfy this gener-ation’s supposed taste for a life of luxury, even duringdental school, leads some of them to dishonest acts.

Anyone in my generation who retains a reasonableamount of their gray matter will remember our days atthe age of current students. That time in our nation’shistory had its fair share of corporate and governmentscandals and badly behaving stars. We didn’t have theInternet, but a portion of our music and other forms ofpopular culture made light of those living by societalstandards or following the rules. Did that make us thinkin a less ethical way or make us more likely to cheat?If it affects current students, can we still claim we weresomehow immune to similar influences during our earlydays in dentistry? And I recall pressures I felt to do wellin dental school to get into my preferred residency andthought I was going deeply into debt in the process. Sowhy do some dentists feel today’s students are some-how more hollow and likely to succumb to temptation?I have no clue. Perhaps it’s simple generational chau-vinism; this is a disorder that each generation predictswon’t happen to them once they enter older age groups.However, for some the belief that their generation hadit harder and that they had more obstacles to overcomethan subsequent ones appears irresistible. But it doesn’tmake it true, because it isn’t. Anyone who spends timewith today’s dental students cannot help but be im-pressed with their spirit and passion. Sure there is arange of personalities and innate talents, but as a groupthey are impressive. Most have accomplished far morebefore entering dental school than many in previousgenerations. Kids today, more often than not, jugglemany more activities before and during college than inmy youth. And I can’t count the number of timesdentists tell me they wouldn’t be able to get into dentalschool if they had to apply now, based on the record

they had when they were accepted.

OOOOE450 Editorial October 2007

I remain unconvinced that today’s generation of den-tal students is any more or less likely to cheat or beunethical in other ways than past students. Data mayarise that show me to be wrong, but until such evidenceis made available, those with the “I had to walk 10miles, in 5 feet of snow to school, barefoot, and it wasuphill both ways” stories should recognize the weak-ness of their position.

The current ongoing discussions about ethics indentistry can be healthy; however, rather than focus-ing on dental schools as the site and source of mostunethical behavior, the discussion must expand to theprofession as a whole. We should not lose sight thatdentists are highly respected and a major reason isthat we have earned the trust of our patients. This didnot happen by accident. It was built upon years offair and honest dealings with patients, one act at atime. In comparison with other professions, dentistsare among the most trusted, and deserve that status.

But we must continuously strive to improve the

ethics of the dental profession. Groups like theAmerican Dental Association, American and Inter-national Colleges of Dentists, American Dental Ed-ucation Association, and dental boards can makeongoing ethical training and monitoring a high pri-ority for membership and continued licensure. Per-haps they can hold a summit to strategically planhow to foster even greater dental ethics. Dentalschools can play an important role, but only as thestart of a continuity of a focus on ethical practicethroughout a dental professional’s career.

James R. Hupp, DMD, MD, JD, MBAEditor-in-Chief

Section Editor, Oral and Maxillofacial Surgery

doi:10.1016/j.tripleo.2007.08.004

REFERENCE1. Bertolami CN. Why our ethics curricula don’t work. J Dent Ed

2004:68;414-25.