Do Patients and Dentists See Ethics the Same Way? Part 2

Eight cases were developed, representing a range of problematic situations that could arise in dentistry. There are existing collections of cases in various styles, but I have followed the model of the late Jim Rule in his wonderful book Ethical Questions in Dentistry.²² Rule’s cases are longer and more detailed than many in circulation, but they were not written to illustrate predetermined positions. Although that slows down the reader, it also reduces the chance that one will imagine unstated facts or screen out inconvenient particulars from “skeletal” cases to make them fit abstract principles or personal preferences. A little of life’s messiness is necessary to be realistic. Although all the cases have multiple dimensions and interesting paths to follow, they are not all dilemmas. The goal is to involve readers in the cases, not allowing them to be theoretical commentators. The full text of the cases can be seen at www.dentalethics.org/idea/. The stem theme for each case and the actions and reasons are shown here in Table 1. 

 

Table 1. Range of Reasons given for Various Ethical Actions Chosen by Patients and Dentists.

 

 

Each case is followed by four to six potential actions, and readers are invited to indicate on a five-point Likert scale how appropriate each action would be. The scale has anchor points of:

1. absolutely
2. probably
3. 50:50
4. doubtful
5. no way

The actions are not mutually exclusive. It might be “absolutely” appropriate to initiate two or more actions at the same time and give just a little possible credence to a third that is similar to a choice that should be avoided entirely. There is seldom exactly one response to an ethical challenge. Usually there are several appropriate things that could be done and more than one way to get it wrong. But a forced selection on behavior is important in ethical situations. Too often we mistake performing an analysis of the situation and an enumeration of relevant principles for an ethical choice. It is not. The only way others will know whether we are ethical is by watching what we do. Each case is also accompanied by four to six “reasons” or important considerations or ethical goals. The reasons are similarly graded on a Likert scale as:

1. decisive
2. important
3. not clear
4. little importance
5. irrelevant

One could think of the reasons as “justifications” or things that might be said in defense if questioned about what we had done. These reasons represent some of the goals one has in mind when taking action. Again, the reasons are not mutually exclusive. Much of our action is intended to simultaneously optimize several goals and stay out of trouble everywhere that might turn up. The structure of the actions and reasons is intended to place respondents in a realistic situation rather than as an academic exercise of picking the right answer on the best theoretical grounds. Dental school may be like that, but life is not.

Norms were constructed from a sample of dentists and patients, each of which reported what they would do and why for all eight cases. The dentist sample consisted of 91 national and section officers of the American College of Dentists who were surveyed by mail. The patient sample was taken from the attendees of two churches in Sonoma, California, totaling 54 responses.

In addition to full descriptive tabulation of the results, t-tests were performed for differences between groups (dentists vs. patients), F-ratios were calculated for homogeneity of variances between multiple groups, a factor analysis with varimax rotation was performed to identify the latent structure in respondents’ views of oral health, and correlation matrices were created to reveal associations among the variables.

This project was approved in the exempt category by the IRB at the University of the Pacific, #13-63.  

 

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Results

Both dentists and patients were able to use the cases in the format presented. They generated a rich dataset of opinions about the ethical dimensions of these eight situations. The average answers run to five pages, and the detail can be viewed in the article beginning on page 34 of http://www.acd.org/_jacd/JACD-82-2.pdf or as feedback when working through the video versions of the cases at https://www.dentalethics.org/videodilemmas.htm. Those using the online form of these cases can see how their choices would be viewed by the public and by colleagues.

Consider an example from the case on hostile workplace environment (Coach) shown graphically in Figure 1. One of the actions offered to respondents was to ignore the hygienist’s complaint that a patients was making inappropriate remarks on the grounds that such matters are personal between the staff and the patient. Dentists overwhelmingly rejected this as a way of handling the matter, 86% saying “no way” and 13% saying “probably not.” Any dentist who thought seriously about ducking issues like this would have to be nimble in creating an excuse for why he or she is different from others in the profession. As it happens, patients see this situation the same way. Among patients, 76% said do not avoid the issue in the strongest possible terms and another 22% considered this a doubtful alternative. Any dentist still thinking that the problem should be left to sort itself out on its own now has to fabricate a justification for the public or perhaps the National Labor Relations Board. Dentists and patients also tended to agree on the reasons various actions should or should not be taken when hostile workplace environments occur.

 

Patients and dentists were of a common mind that employee morale, the law, value in good interpersonal communication skills, and the dentist’s sense of integrity are strong reasons for confronting the issue. Slightly less important were reasons such as abstract matters of civil liberties and the dentist’s reputation in the community.

There are examples such as this throughout the cases were patients and dentists agree that certain actions and reasons are obviously correct. There are also situations that are more challenging. For example, patients and dentists often disagree regarding a dentist’s responsibility for challenging colleagues who are doing faulty work. Not all issues are ones where there is near uniformity in the right action or right reason. For example, dentists are of mix mind regarding whether to dismiss a patient who reneges on payments; the entire range from “absolutely” to “no way” being advocated by many respondents. All of these outcomes where there is no consensus can be valuable for stimulating reflection.

Principles are like a handpiece: they are a tool for doing better dentistry. Knowing about principles is like knowing about handpieces. The real result comes from repeated practice in individual situations. The eight ethics cases in this program are like the mannequin students used in preclinical technical. They are a good place to start learning.

 

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Understanding the Norms

The database can also be studied to learn about patients’ and dentists’ views of dental ethics in general. Are there patterns in the way the public or practitioners expect dentists to behave or what reasons are appropriate for the way dentists should act? Do patients place more or less weight on ethics and do they see particular situations the same way dentists do? Do we need CE courses on personnel law or on inter-professional management of patients? This is a rich dataset in which to explore such questions.

Figure 2 is a graphical representation of one of the potential actions a dentist might consider in Case 3, “Who Cares.” It shows the percentage of respondents selecting each of the five options from strongly favorable to strongly unfavorable for taking up with the component society the issue of specialists not returning patients to the referring general practitioner. On average, patients tend to favor raising the concern at the professional level (an average of 3.13 on a five-point scale, where 2.00 is neutral) while dentists shy away from that (averaging 1.86, more toward the “no way” end of the scale). This difference is highly significant (p < .001 by the conventional t-test for differences between averages). Further, the standard deviation for patients is .89 compared to the statistically significantly larger standard deviation of 1.21 for dentists. Dentists are more divided in their opinions than are patients. Graphically, the differences in appropriateness of the action is clear as a shift in the two peaks on the curve (patients more toward the action end of the scale). Graphically, the difference in consensus of opinion is represented by the overall flatter curve for the dentists (there are many dentists willing to follow each of the alternatives).

 

 

In the set of 37 possible ethical actions in the entire set, the most prominent differences between patients and dentists include the following. Dentists are more apt to favor upfront payment, comprehensive treatment plans, limited informed consent, and confidential management of differences among colleagues. Patients value adjustments of payment alternatives and spacing of treatment, full informed consent, better patient education, active and open engagement of colleagues who are not practicing at the standard of care, and greater involvement of dentists in the general oral health needs of the community.

A striking illustration of the divergence in valued actions concerns a patient who requests veneers on teeth with questionable anatomical support. Should the dentist educate the patient regarding a long-term treatment plan based on health instead? Ninety-three percent of patients say “yes” while 93% of dentists say “no,” the apparent reason being partially related to suspicions that this is an “independently minded” patient. More than half the dentists (56%) would refer such patients out of their practices, a policy endorsed by only 31% of patients. Another such example of divergent opinions regarding management of patients whose expectations differ from those of the practitioner involves renegotiating treatment and payment for a patient who is dissatisfied with the initial work performed by the dentist and not inclined to pay for it. Both patients and dentists agree strongly that letting the patient off the financial hook is inappropriate. But the typical response among patients is to explore breaking treatment plans and payments into segments. Among dentists almost 75% would look unfavorably on this action. Patients are more apt than dentists to favor referring the patient to peer review for adjudication of the disagreement.

 

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Agreement Between Dentists and Patients

The Likert responses on each item were converted to a 4-to-0 scale and the average was taken for each item for patients and for dentists, collapsing the dataset to 37 actions and 47 reasons. The correlation between patient and dentist average scores for actions was r = .806. The correlation across averages for the reasons was r = .911. There is very high global agreement between dentists and patients in how to act and why across the eight cases studied.

 

Is There One Best Answer (Issue Ambiguity)?

There was consensus on some actions and reasons and a range of responses on others. Only a dentist who was outside the tight range would need worry about these ethical issues, and by definition these practitioners will be in the minority. The profession needs to turn its attention first to those issues where there is little settled opinion. Those challenges where dentists agree with each other and patients are in agreement that something else should be done are also critical and will be discussed below. How wide is the range of preferred responses?

Table 1 presents the results of the first of several analyses intended to show the underlying structure in these data. Of the 37 action items and the 47 reason items, there were none where a single one of the five scale values was agreed by either all patients or all dentists. In 55% for actions and 68% of reasons, all five alternatives were selected by somebody from “absolutely/decisive” through “no way/irrelevant”. This diffuse pattern was also reflected in the modal responses. Where there was consensus, the distribution will be peaked and a large proportion of the responses will be in the mode (most commonly chosen alternative). The mode could range from a low of 20% (meaning that all five alternatives were chosen an equal number of times) to 100% (meaning that one alternative was always selected). Across all 84 items, the average modal response clustered near 50%, meaning that the most popular action or reason was favored by roughly half of the respondents. Alternatively, patients or dentists who chose the response favored by most of their peers were in disagreement with half of those in their group. Patients and dentists were equally spread on both actions and reasons. Dentists were equally spread on their choices of actions and reasons, but patients were slightly more concentrated on reasons than on actions. Items with large standard deviations tended to have larger numbers of missing values, r = .197. This can also be interpreted as a sign of ambiguity – respondents simply chose not to register an opinion and, presumably, would try to avoid rather than address such challenges.

The issues that drew the widest range of opinions for both patients and dentists (standards deviations above 1.25) included truthfulness in filing insurance claims, taking action regarding other dentists’ questionable behavior, involving all staff in the hostile workplace matter, and extent of informed consent deemed appropriate. Providing care when the patient is making irregular payments was more of an unsettled issue for dentists than for patients.

 

Matching Actions to Reasons

It is possible that there are tight connections between actions and the reasons used to justify them – each action based on a dominant reason. It is also possible that reasons support multiple actions. The approach to ethics based on principles assumes that there is a reasonably tight connection between reasons and actions. If that is not in fact the case, the importance of ethical principles is diminished. To explore this possibility, all correlations were calculated between actions and reasons and the average taken on a case-by-case basis. The average across all eight cases was r = .104. This means that reasons were not specific to actions. Further evidence for negligible action-reason pairing was found by locating those cases where a single reason was associated with a single action. Only 26% of the reasons motivated a single action (operationalized as a correlation significant at the p < .05 level), while 40% motivated multiple actions and 34% were not systematically associated with any action. Analyzed from the opposite perspective, 31% of the actions were significantly associated with a single reason, while 44% had multiple motivations, and 25% had none. This finding raises questions about grounding ethical analysis in principles, or at least in expecting to find that principles lead predictably to actions.

 

Level of Ethical Justification

Forty-seven different reason for ethics in dentistry is too many to work with. We need to find meaningful groupings. When psychologists, rather than philosophers, study ethics, they look to levels of reasoning or the origins of the standards. A well-established classification system is James Rest’s three categories, which I have modified slightly to emphasize the location of the standard for making ethical choice. Each of the reasons for actions in this study was assigned to one of the categories of Self, Group, or Ethics, and the results are summarized in Table 2. Reasons that are based on self-referential standards, such as the Golden Rule, look for guidance to the impact an action would have for the person taking the action. Group norms depend on what one’s peers would regard as appropriate. Ethics standards are grounded in theoretical principles presumed to be universal regardless of who is involved.

Self and Group justifications were valued to about the same extent, but Ethical reasoning was preferred or given stronger credibility. This grouping was statistically significant. There were no differences between patients and dentists on this score. The literature generally reports that individuals seldom come up with fully Ethical justifications on their own.16 The current study found that where such reasons are provided, they carry weight.

 

Table 2. Average (Standard Deviation) of Endorsed Reasons for Actions Classified by Moral Reasoning Level.

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Underlying Structure, Ethical Dimensions of Dentistry

Thirty-seven different courses of action is also too many to work with individually. It is human nature to look for patterns. One might be tempted to say, for example, some dentists are master technicians and others are born salespersons. Some are both and some are neither, but we still like to use such typologies. Some office staff have names for certain kinds of patients. Every case does not fit perfectly in such systems, but we keep using them because, on the whole, they guide action with few surprises. There is a formal statistical procedure called factor analysis that uses the computer to identify natural dimensions in data based on how respondents group their responses. Factor analysis calls out dimension rather than clusters, so a particular item can “load” (have common properties) on several factors, just as one’s neighbor can be politically conservative and religiously indifferent. Combined patient and dentist responses for all 37 actions were submitted to principle components factor analysis with a varimax rotation. Factors were retained based on analysis of scree plots, eigenvalues above 1.0, and meaningfulness of suggested interpretations. Table 3 shows the five factors that were extracted, which together accounted for 57% of the variance. Only items with significant factor loadings are shown.

 

Table 3. Factor Structure among 37 Actions on 8 cases, 148 Combined Patients & Dentists.

 

 

Table 3 shows a very clean, five-factor structure. Most actions load on a single one of the five underlying dimensions. The most prominent factor is labeled Oral Health orientation. Items loading on this factor mention positive patient health status independent of treatment activity. The second most prominent factor (Technical Focus) selected for specific treatment, appropriateness of treatment, or managing work flow or financial relationships. Professional Engagement, the third factor, included items describing dentist-to-dentist relationships. The fourth factor was the classical ethical principle of Respect for Autonomy. A final dimension has been included for the sometimes mentioned practice of Paternalism. Actions loading on this factor include behavior where the dentist alone determines what is in the patients’ best interests. The same factor structure emerged when separate factor analyses were conducted for patients and for dentists.

Occasionally in such situations, a single global factor emerges, instead of the five mentioned above, in a preemptive position that explains most of the variance. This was not the case here, but had that been so, it would have supported the view that there is a global construct – “being ethical” – which characterizes some dentists but not others. This analysis suggests that ethical dental practice is more nuanced and situation-specific.

 

Ethical Dimensions of Dentistry as Seen by Dentists and Patients

More than half the variation (57%) in the actions chosen by patients and dentists in these ethical dental situations was explained by a five-factor underlying structure. If we know where people stand on these dimensions, we would be able to predict with some confidence how they would act when presented with ethical challenges. It would be helpful to know whether this five-factor structure is applicable to both patients and dentists independently. A tentative answer is sketched in Table 4.

 

Table 4. Average Preferences (Standard Deviations) for Actions of Various Types among Patients and Dentists (including only items identified in factor analysis).

 

 

Respect for autonomy, willingness to include others in the decision making process, appeared as a leading ethical dimension for both patients and dentists. After that, some differences begin to appear. Patients placed a greater salience on behavior that ensures positive oral health outcomes than did dentists. Dentists focus more on the technical aspects of dental treatment. Patients were very significantly more concerned that dentists should engage in professional interactions with colleagues on patients’ behalf than were dentists.

Ethical Dimensions of Dentistry and Levels of Ethical Reasoning

Table 5 shows the correlation coefficients between moral reasoning level and types of actions most valued by patients and by dentists. This is a summary of the extracted five dimensions of actions and the three levels of reasons instead of the nearly 400 relationships among the raw data points. We might suspect that patients with different moral reasoning styles have different expectations about the dental office experience. Patients favoring Self-focused, rule-based approaches over other ethical orientations tended to devalue both oral health outcomes and respect for autonomy. Those with Group orientations were what might be called “casual” with regard to the way dentists preferred to run their practices. The general norm in the patient community contains ambivalent expectations. Those patients who placed a high value on understanding issues from the Ethical point of view were keen on respect for autonomy, they want to be independent moral agents.

 

Table 5. Associations between Action Types and Moral Reasoning Level.

 

 

Dentists presented a slightly different picture of the relationship between level of ethical reasoning and their structuring of ethical actions. Self-focused reasoning was associated with actions keeping practitioners out of engagement with their colleagues or the professional generally. Group thinking was associated with attention to the business of dentistry and technical performance. The dominant norm by which dentists judge each other appears to be performing technically fine treatment and running a successful practice. Higher Ethical reasoning was negatively associated with paternalism. Seeking the grounds for ethical practice in general standards was considered inconsistent with acting as one’s own standard.

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Discussion

Eight extensive cases of ethical situations that arise in and around dental practice were reviewed by 54 patients and 91 dentists. The respondents indicated their degree of agreement with multiple courses of actions and justificatory reasons in each case. This dataset was used to create an online interactive ethics learning platform where individual dentists can compare their considered actions and reason against norms from their peers and from a sample of patients. The dataset has also been analyzed in detail to identify the underlying structure of ethics in dental practice.

[su_pullquote align=”right”]The public and the profession seemed to have different perspectives on the primacy of technical procedures and oral health outcomes and on how far paternalism should be carried.[/su_pullquote]Although there was substantial agreement on actions and reasons at the aggregate level (patients as a cohort and dentists as a cohort), there were patterns of particular differences that deserve further exploration. Such topics as justifiable criticism, informed consent, financial arrangements and patient responsibility, and dentists’ role in oral health beyond the purely technical tasks suggested themselves as very promising for policy discussion and education. These are areas where wide differences of opinion appeared and where a range of opinions existed among dentists. The public and the profession seemed to have different perspectives on the primacy of technical procedures and oral health outcomes and on how far paternalism should be carried. Another place where patients and dentists seemed to be looking in different directions was on the dentists’ obligation to engage colleagues or the profession as a whole on the patients’ behalf.

Policy discussions, code revision, and continuing education should focus on those issues where there are material differences in the courses of action preferred by patients and dentists and where dentists exhibit a range of opinions on situations. Challenges where consensus already exists are poor candidates for education, but may be areas where more active enforcement is needed.

Practical dental ethics is complex. There is little evidence in this study for grounding dental ethics in theories of ethics. There was no evidence for a general construct – “ethical dentist” – that applies across the boards or for courses of actions to flow directly from principles. John Stuart Mill seems to have been correct in noting “there is no case of moral obligation in which some secondary principle is not involved.”17 The fact that a factor structure with five dimensions emerged rather than a global “ethical / not ethical” dichotomy is consistent with the literature, including the classical Hartshorne and May study showing that children would steal a lunch but not a pencil or cheat on a test but not in a game, and various individual combinations.11

It is not customary for professions to include patients or the public in the development, interpretation, or implementation of their ethics codes. Jürgen Habermas offers a helpful rule in this regard: all competent individuals who are affected by a decision should be allowed to participate in the decision.10 Competence in the case of individuals in need of oral health care obviously extends beyond the technical aspects of treatment, as evidenced by the content of most professional codes, and participation can certainly be representative. To the best of my knowledge, no lay individuals were involved in the development of the ADA code and its exact shape and use are strictly controlled by the House of Delegates. By contrast, Institutional Review Boards which are required to pass on all research involving human subjects in America are not permitted by federal regulation to take a vote on any specific proposed project unless there is at least one lay committee member among the quorum (See 45 Consolidated Federal Record 46).

The level of justification or touch-stone source of deciding what is right to do that was supported by the data in this analysis seems intuitively correct. The Self as standard was associated with unattractive actions for both patients and dentists. These included diminished concern for oral health outcomes, limited professional engagements, and low respect for autonomy. Accepting the norms of one’s reference Group appeared to be matched with focus on technical and business aspects of practice for dentists and with patients inclined to “show some for the best deal.” This is a transactional perspective on oral health care. High level of Ethical reasoning emerged as antithetical to paternalism or the imposing of ones views on others and with the patient as an autonomous moral agent. This would be a definition of oral health based on relationships.

The five-factor structure of dental ethics issues produced by the factor analysis approach seems face valid. Oral health outcomes and technical and practice excellence should be on everyone’s list as highly valued signs of the best practices and as reflections of the fundamental integrity of dentists. These concepts are present in various places in the ADA code and the codes of specialty and other dental groups.

Paternalism (or more properly limited appeal to it) and individual members and the profession’s active self-policing on behalf of patients appeared as dimensions of both patient and dentist’s ethical framework. It seems as though this matters a bit more to patients than to dentists. There is evidence suggesting that Professional Engagement, especially among the most ethical members of the profession, is a more powerful influence on the ethical character of dentistry than are enforcement actions against those who bend or break the rules.6 This is an area the profession will find fruitful to explore.

Respect for autonomy was the only ethical dimension that emerged prominently in the present dataset of ethical concerns that is also one of the five organizing principles in the ADA Principles of Ethics. But the fit is not as tight as we could hope. This is the first of the Belmont principles (“Respect for Persons”). The ADA version was changed to feature “Patient Autonomy”.7 Certainly respect is implied although not stated, but there are significant differences between patients and persons. Much of the public would not consider itself currently to be patients of record of a dentists, and some of the ethical issues studied here, such as agreement on treatment plans, care for institutionalize individuals in need of treatment, and agreement on payment and selecting and following treatment plans, are exactly about who should be considered a patient rather than on how patients should be treated. I have long argued that dentists are entitled to exactly the same respect that patients and the public at large have. I would prefer the Belmont language.4,5

Finally we must return to the beginning and see what has been learned about the role of principles in dental ethics. Philosophers have shown clearly that we can get the job of ethics done just as well without as with principles.12,9,21 A case can be made that patients and dentists can agree with each other generally in practice without sharing a common language or appeal to principles. There was very little support in these data for a direct connection between reasons for ethical behavior and the actual actions chosen. The five-factor structure for ethics that emerged from analyzing the choices patients and dentists actually made did not match well with systems of principles derived by philosophers.

Aristotle seems to have held reservations about the usefulness of ethical principles. “If theories were sufficient of themselves to make men good, they would deserve to receive any number of handsome rewards. . . . But it appears in fact that, although they are strong enough to encourage and stimulate the young who are already liberally minded, although they are capable of bringing a soul which is generous and enamored of nobleness under the spell of virtue, they are impotent to inspire the mass of men”.1

Principles are useful as theoretical organizers, as the carrying cases for examples of the behavior dentists expect of each other and the public expects of dentists. But they are not the behavior itself or even possibly not the best characterization of the patterns of that behavior.

Further work is needed along these lines to clarify what will most improve oral health and how dentists can know they are on the right path. Working with cases, lots of them over a long time frame and with feedback from colleagues and the public, bid fair to serve this need.

 

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This article is a slight modification of a paper that appeared in the second issue of 2015 of the Journal of the American College of Dentists, and is reprinted here by permission.

 

About Dr. Chambers

David W. Chambers is professor of dental education and former associate dean for academic affairs and scholarship at the University of the Pacific, Arthur A. Dugoni School of Dentistry in San Francisco. He is also the editor of the American College of Dentists. He has served as a consultant to most national dental organizations and dental schools in the United States and Canada, as well as being an examiner for the Malcolm Baldrige National Quality Award and on the Commission on Dental Accreditation. He has earned EdM, MBA, and PhD degrees. He has published over 500 papers in his areas of interest, which include competency-based education, ethics, evaluation, and critical thinking. Dr. Chambers has been a visiting scholar in philosophy at Cambridge University, England; University of California, Berkeley; and the London School of Economics exploring moral issues.

 

References

1. Aristotle (1920). The Nicomachean Ethics. J. E. C. Welldon, Trans. London: Macmillan.
2. Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics, 6th ed. New York, NY: Oxford University Press.
3. Bertolami, C. (2004). Why our dental ethics curricula don’t work. Journal of Dental Education, 68(4), 414-425.
4. Chambers, D. W. (2003). Standards. Journal of the American College of Dentists, 70, 61-64.
5. Chambers, D. W. (2013). Would someone please explain what it means to be ethical? CDA Journal 41, (7), 493-497.
6. Chambers, D. W. (2014a). Computer simulation of dental professionals as a moral community. Medicine Health Care and Philosophy, 17, 467-476.
7. Chambers, D. W. (2014b). Does the ADA have a code of ethics? CDA Journal, 42 (12), 813.
8. Council on Dental Accreditation (2013). Predoctoral dental education standards. Chicago, IL: American Dental Association.
9. Dancy, J. (2004). Ethics without principles. Oxford, UK: Oxford University Press.
10. Habermas, J. 1990). Moral consciousness and communicative action. C. Lenhart & S. W. Nicholsen, Trans., T. McCarthy, Intro. Cambridge, MA: MIT Press.
11. Hartshone, H., & May, M. A. (1928). Studies in the nature of character. New York, NY: Macmillan.
12. Hooker, B. (1999). Rule-consequentialism. In H. LaFollette, Ed. The Blackwell guide to ethical theory. Oxford, UK: Blackwell, pp. 183-204.
13. Jonsen, A. R. (1991). Casuistry as methodology in clinical ethics. Theory and Medicine, 295–307.
14. Kohlberg, L. (1968). The child as a moral philosopher. Psychology Today, 7, 25-30.
15. MacIntyre, A. (1988). Whose justice? Which rationality? Notre Dame, IN: University of Notre Dame Press.
16. McNeel, S. P. (1994). College teaching and student moral development. In J. R. Rest, & D. Narváez, Eds. Moral development in the professions: Psychology and applied ethics. Hillsdale, NJ: Lawrence Erlaum Associates, pp. 27-49.
17. Mill, J. S. (1863/1920). Utilitarianism. A. D. Lindsay, Intro. London, UK: J. M. Dent & Sons.
18. National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1979). The Belmont Report: Ethical principles and guidelines for the protection of human subjects in research. Washington, DC: Department of Health, Education, and Welfare.
19. Rest, J. (1973). The hierarchical nature of stages of moral judgment. Journal of Personality, 41, 86-109.
20. Rest, J., Narvaez, D., Bebeau, M. J., & Thoma, S. J. Postconventional moral thinking: A neo-Kohlbergian approach. Mahwah, NJ: Lawrence Erlbaum Associates, 1999.
21. Rorty R. (1999). Ethics without principles. In R. Rorty. Philosophy and social hope. London, UK: Penguin, Books, pp. 72-90.
22. Rule, J. T. & Veatch, R. M. (2004). Ethical questions in dentistry, 2nd ed. Chicago, IL: Quintessence Publishing.
23. Thornton, T. (2005). Judgment and the role of the metaphysics of values in medical ethics. Journal of Medical Ethics, 32(6), 365–370.

 

 

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