THEMATIC ARTICLE
Mary E. McNally,
Joseph H. Murphy, Karen McEwen & Helen A. Ryding
A Collaborative Approach to
teaching Dental Ethics and Law Across the Curriculum
The dental ethics and law curriculum at Dalhousie University has been developed through a partnership between the Faculty of Dentistry and the Health Law Institute in the Faculty of Law. Some years ago, it was recognized that increasing complexities associated with the practice of dentistry (e.g., technological advances, emphasis on aesthetics, escalating costs, unequal access), underscored the need for solid grounding in the legal and ethical domains of professional practice. A set of didactic lectures in one semester no longer seemed adequate.
The objectives of the Dalhousie Curriculum are to develop dental students’ understanding of:
Professional and public responsibilities
Ethical theories and frameworks used to examine the ethical dimensions of professional practice and clinical decision making
Relevant health and dental law
Process
Dental ethics and law content is taught through what we refer to as the “Spiraling Curriculum” within the four-year Doctor of Dental Surgery Program (Table 1). Consisting of approximately 40 hours of curriculum time over the four years, topics are introduced in first year and are reintroduced in each subsequent year of the program. Content increases in breadth and complexity as students advance through second, third and fourth years. For example, in first year, issues of informed consent and confidentiality are examined very broadly in the context of both ethical theory and as ethical and legal corollaries of “respect for autonomy”. In years two and three, details regarding the breadth of these duties as well as the accompanying relevant law are introduced. In fourth year, this knowledge is applied to a variety of cases. The rationale is that material covered from years one to three prepares students to competently research and examine complex cases.
|
|
DDS 1 |
DDS 2 |
DDS 3 |
DDS 4 |
|
Law |
6 hours total - Intro Cdn legal system (1.5) - Intro Cdn health care system (1.5) - Informed consent (1) - Confidentiality (1) - Record keeping (1) |
7 hours total - Social justice, discrimination cases (1) - Informed choice (1) - Confidentiality (1) - Duty to treat (1) - Research involving humans/animals (1) - Record Keeping (1) - Drug law (1)
|
7 hours total - Drug Law (1) - Licensing, regulation, & privileges (2) - Negligence, Malpractice (2) - Intra and Inter-professional issues (e.g. whistle-blowing, dental team) (2) |
Attendance at 3 one-hour seminars for case discussion. Preparation consists of assigned readings and a written reaction summary expected to take students 2-3 hours of preparation. |
|
Ethics |
10 hours total - Intro ethics (1.5) - Ethical theory (1.5) - Professionalism & Codes of ethics (2.0) - Decision making (2.0) - Informed choice/ Confidentiality (1.5) - Case review (1.5)
|
6 hours total - Social justice (diversity, equality, access) (2) - Informed choice (1) - Confidentiality (1) - Duty to treat (1) - Research involving humans (1) |
3 hours total Intra and Inter Professional issues - Nova Scotia Dental Assoc (1) - Provincial Dental Board (licensing body) (1) |
Table 1 – Summary of DDS Curriculum, Dalhousie University
Instruction
As mentioned, the Dental Ethics and Law program has developed as a result of a partnership between health law experts and dental faculty with expertise in ethics. The overall curriculum is overseen and coordinated by a faculty member in Dentistry although scheduling and hiring of law instructors occurs within the Health Law Institute. At least half of the curriculum is “team taught” where a member of each faculty is present to cover content and to engage in case discussion together. Students have a comprehensive reading list of both ethics and law to accompany the program each year.
Evaluation
Grades consist largely of small assignments (written, class presentations, role play) and are given an open book examination. Every effort is made to ensure that examination questions are developed so that students will “apply” their knowledge from readings and class participation. Students are also rewarded with an attendance and participation grade.
Lessons Learned
Initiated in 2000, the curriculum has evolved in a number of ways. Although instructors and teaching approaches have varied somewhat, content covered in years 1-3 of the curriculum have remained quite consistent since rolling out the curriculum in 2000. There have, however, been significant changes to the fourth year program. Initially, students in fourth year were asked to work in groups (of 3-4) to examine and analyze a particular case scenario. With a very explicit set of guidelines each group was responsible to both prepare and present their findings to the class. To ensure that students were “on track” with both concepts and research, they prepared a three page written summary and were given detailed written and verbal feedback from instructors to assist with their presentation. Despite these measures for feedback and coaching, there were many instances where students simply “got it wrong” when it came to the content of their presentations. Instructors who were overseeing the presentations were available to ask questions of clarification and to make relevant corrections to the content. However, this approach was problematic in a number of ways:
1 - Because they were not required to do an examination on all cases and material, instructors were concerned that students were only learning about their own cases.
2 - When material presented was incorrect, feedback at the time of case presentation was difficult and sensitive. Instructors did not wish to “roast” students in class. However, making corrections was necessary for students who were about to graduate.
To overcome this difficulty, the curriculum for 4th year students has been modified significantly. Although a case approach is still employed, reading materials are provided by instructors. Students are required to attend 3 seminars for case discussion. Prior to seminar, they prepare a written reaction summary related to the case and readings which is graded and feedback provided by instructors. Evaluation also includes an open book exam for all material covered. This approach has significantly improved the accuracy of content covered. One difficulty that remains is that “paradigm cases” have been developed to ensure that the correct content is covered. It is known that students share information on both reaction summaries and examination expectations so instructors are constantly challenged to keep the cases and content fresh.
The development and sustainability of this curriculum requires a great deal of faculty resources and coordination between the Health Law Institute and the Faculty of Dentistry. It is dependent on the maintenance of a healthy partnership.
Sample cases and discussion points used in the DDS4 curriculum
Negligence
Describe what liability in negligence a dentist will have if she extracts a patient’s wisdom tooth and during the extraction the mandibular nerve is damaged resulting in permanent paraesthesia. This question will involve setting out the legal test for negligence and considering in what circumstances a dentist would likely be found liable.
Reflect and comment on the difference between “clinical misadventure” and “negligence”. What ethical values, principles and virtues are at issue in this particular case? Describe how the law does (does not) reflect these ethical principles and standards.
Informed Choice and Capacity
Jack is an 82 year-old retired fisherman and widower. Since moving to the city 10 years ago (to be closer to his children), he has been a patient at a local dental clinic. Recently, Jack attended the clinic for a routine examination and cleaning. Normally, Jack is very talkative, bright and cleanly dressed. On this visit, however, the dentist noticed that he was disheveled and very distracted. The dentist was concerned for Jack’s well-being and his state of mind. On examination, the dentist found an abscessed molar. The dentist spoke with Jack and recommended antibiotics and a follow-up visit for tooth extraction. Jack did not appear for the follow-up appointment and when the receptionist called to see what happened, Jack said “I guess I must have forgot ... I forget a lot of things these days...” The receptionist rebooked the appointment for the following week. Again, Jack did not show for the appointment and when the receptionist called this time, Jack appeared confused about the nature of the call, got upset and said he did not want to be treated. What are the dentist’s legal and ethical duties in this situation? Describe how the law does (does not) reflect underlying ethical principles and standards.
Dental Research
A local dentist attended a continuing education program that provided information regarding a new experimental nonsurgical therapy for the treatment of periodontal disease. Early research relating to this therapy looked very promising and the dentist is very anxious to implement it. The developer of the experimental procedure approaches the dentist to see if she would be interested in participating in a research study involving the new therapy. How is dental research regulated in Canada? Consider both the sources of regulation and the process of regulation of research in Canada. Identify and discuss the dentist’s legal duties and ethical obligations to her patients both as a researcher and a clinician. Are these ever in conflict? Discuss.
Discipline – Substance Abuse
Recently, Dr. Brown, one of the dentists in a rural group practice arrived at work smelling strongly of alcohol. The dental hygienist smelled this and told Dr. Black, one of the other dentists and she also told him that this was not the first time she had noticed alcohol on Dr. Brown’s breath. Dr. Brown’s first patient was scheduled for a routine six-month checkup. Dr. Black told the hygienist to let Dr. Brown do the checkup but that she should cancel the rest of the day’s appointments. During the patient’s examination, Dr. Brown discovered a cavity. As Dr. Brown was drilling the tooth, he seriously lacerated the patient’s gum and also fractured one of the patient’s crowned teeth. Discuss Dr. Black’s ethical and legal duties with respect to reporting Dr. Brown to the Provincial Dental Board. Describe how the law does (does not) reflect underlying ethical principles and standards. Consider how regulatory bodies deal with the impaired/incapacitated dentist.
About the Authors
Dr. Mary E.
McNally is an Associate Professor at the Faculty of Dentistry, Dalhousie
University
Dr. Joseph H. Murphy is an Associate Professor and Assistant Dean of Students,
Dalhousie University (retired)
Dr. Karen McEwen is Director of Professional Practice at the Pembroke Regional
Hospital in Pembroke Ontario
Dr. Helen A. Ryding is an Associate Professor and Associate Dean, Academic,
Dalhousie University (retired)
Correspondence
The authors can be reached at Mary.McNally@dal.ca
Citation
McNally, M. E., Murphy, J. H., McEwen, K. & Ryding, H. A. (2009). A Collaborative Approach to teaching Dental Ethics and Law Across the Curriculum. Bulletin of the International Dental Ethics and Law Society 9(2), 14-18.
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