The first five years

The first warning sign of a lack of conceptual clarity in the GDC's approach to professionalism and ethics is to be found in the third edition of The first five years (TFFY), where professionalism is discussed under the heading 'Student fitness to practise'.1 While it is certainly necessary to be unprofessional in order to have one's fitness to practise called into question, it is equally true that one can be quite unprofessional without fitness to practise (FTP) ever being called into question; fitness to practise and professionalism are two quite distinct concepts. TFFY goes on to state that 'the scope of what Council requires of undergraduates goes beyond academic achievement, and incorporates the attitudes, values and behaviours needed for registration'.1 These requisite qualities are set out in the separate document Standards for dental professionals (SDP), which will itself be discussed later in this paper. TFFY states in section 7 that:

The Council expects professionalism to be embedded throughout undergraduate dental education programmes. All dental students must have knowledge of our ethical guidance Standards for dental professionals, and its associated guidance, and demonstrate their professionalism, which must be continuously measured against the principles set out in Standards for dental professionals.1

Again, there is a lack of clarity here. First, the teaching of professionalism and assessment of professionalism can perhaps be 'embedded' throughout the BDS course, but it is unclear what is meant be embedding professionalism itself in the course. Second, is SDP ethical guidance or a set of professional benchmarks? In the sentence quoted above, it is clearly regarded as both, which is the heart of the problem. Just as professionalism and fitness to practise are distinct concepts, so too are professionalism and ethics. The precise nature of these distinctions will be discussed in the third section of this paper.

After sections 6 and 7 of TFFY, sections 8 to 13 turn to concrete issues of FTP; sections 14 and 15 concern assessment, and it is stated that 'Professionalism should be assessed throughout the programme.'1 The difficulty of assessing professionalism is also discussed in the third section of this paper.

Standards for dental professionals

The six main principles of the SDP guidance are also quoted directly in TFFY. The SDP document itself states under the heading 'The principles of practice in dentistry' that:

'As a dental professional, you are responsible for doing the following:

  1. 1

    Putting patients' interests first and acting to protect them

  2. 2

    Respecting patients' dignity and choices

  3. 3

    Protecting the confidentiality of patients' information

  4. 4

    Cooperating with other members of the dental team and other healthcare colleagues in the interests of patients

  5. 5

    Maintaining your professional knowledge and competence

  6. 6

    Being trustworthy' 2

Although this seems like a sensible list of key principles, there are several distinct and overlapping concepts at play here. The first three principles are all derived from the (currently) paramount principle of biomedical ethics, respect for autonomy.3 Respecting patients' choices is ethically essential as they have the right to decide what is done to their bodies (references to dignity are common in professional guidelines, but it is often extremely unclear what is meant by the phrase). Protecting confidentiality also derives from the principle of respect for autonomy because any medical data concerning a patient is his or her information, just as it is his or her body, and s/he has the right to decide what is done with it. And putting patients' interests first is clearly an appeal to their right to self-determination, combined with the principle of beneficence, ie act to benefit patients. These first three principles are certainly admirable, even if they could be condensed to one stating that dentists should 'respect patient's autonomy and attempt to benefit them' (in itself a combination of Beauchamp's and Childress' principles of respect for autonomy and beneficence).

Principles 4 and 5 respectively concern teamworking and continuing professional development (CPD). It is obvious that things will go better for patients if members of the dental team work well together. Maintaining professional competences is also very important, as the dentist who fails to keep up to date with best practice might well find him or herself accused of failing the Bolam test for negligence, which examines whether other dentists would use the same (perhaps outdated) technique. Once again, these are sensible principles, although they are quite different from the first three. If the first three principles are classically ethical, the fourth and fifth are more about professionalism: specifically, acting professionally with colleagues and acting professionally by maintaining one's professional skills.

The sixth principle is of a different order entirely. Although being trustworthy certainly concerns ethics, the first three principles are intended to help guide ethical action: this last one is recommending a particular ethical virtue. It is indeed the case that being trustworthy is a virtue in a professional, and it will probably lead to more ethical outcomes, but it is also vaguely alarming that a profession feels it needs to tell its members to be trustworthy. Furthermore, this last principle seems to be designed as a catch-all in case there are any gaps that the other principles don't cover. A dentist is hiding alcoholism? Hasn't actually harmed any patients, but has deceived his colleagues? Then he's not trustworthy. Another problem with virtues, as we shall see in the fourth section, is that they are rather difficult to teach.

Ethics, professionalism, and fitness to practise

The GDC's revalidation proposals place 25% of the assessment on professionalism; as Trathen and Gallagher state in their recent paper, 'If professionalism is going to form 25% of an assessment of such gravity that it justifies removal from the register, it stands to reason that all parties involved should have a very clear understanding of what professionalism actually is.'4 This is certainly true, and the GDC's labelling of the other 75% of revalidation assessment indicates just how important clarity is in this regard. In addition to professionalism, dentists are to be assessed on 'communication', 'clinical' (skills?) and 'management and leadership'.5 This might seem like a sensible division of assessment, but a dentist could also be unprofessional in any of these latter three areas: s/he might be great clinically but an unprofessional communicator; s/he might be great with patients and clinically but unprofessional as a leader; s/he might be great at communication and leadership but severely lacking in his CPD, with consequently negligent clinical skills. It seems strange that the GDC should insist in one document on the embedding of professionalism within dental curricula, while implementing a system of assessment that artificially divorces professionalism as a separate entity from other areas of assessment.

Trathen and Gallagher praise the 'clarity and care' of the definition of professionalism provided by the Royal College of Physicians (and go on to use it as the basis for their proposed definition of dental professionalism):

'...most of the commitments are based on ethical principles widely valued in our society regardless of the professional status of the individual. Integrity and compassion are certainly not monopolised by the medical and dental professions. They are ethical ideals that in our society are internalised from a young age, and the RCP commitments merely make explicit a number of general moral principles they have deemed most relevant to the pursuit of professionalism.' 4

What are these ethical principles? The RCP states that 'doctors are committed to integrity, compassion, altruism, continuous improvement, excellence and working in partnership with members of the wider healthcare team'. The first thing to notice is that the RCP states that these are 'values', rather than principles, but the first three are clearly virtues; in addition to excellence, the other two are simply variants of the GDC's own CPD and teamworking requirements. These are all very admirable things, but also very idealistic and abstract: how are integrity, compassion and trustworthiness to be taught and assessed?

In a nutshell, the problem with accurately assessing professionalism is that it is predicated upon detecting lapses in professional behaviour; deviations from the expected standard. In the university context, course coordinators can certainly set essay and exam questions on professionalism, but candidates know what they ought to say: the question is whether they actually act professionally with patients. And while methods of assessing clinical performance can certainly include a score for professionalism, it is to be expected that most students will score quite highly in this regard: only those students who score below a certain threshold will be regarded as failing on professionalism. At Glasgow Dental School, where a score for professionalism is included in such assessment, a system is being introduced whereby any student scoring 1-3 (on a nine-point scale) will be referred to the year coordinator. Repeated low scores for professionalism could trigger Fitness to Practise proceedings within the Faculty of Medicine. This reflects the asymmetry described earlier in this paper: if there are questions about a student's FTP, lapses in professionalism are necessary, but there can be occasional lapses in professionalism without any question of FTP. The concepts of FTP and professionalism are closely related but far from identical.

Ethics is another matter. It is unethical to be unprofessional, and unprofessional to be unethical, but there are many differences between the two concepts. Here I must take issue with Trathen and Gallagher's definitions of professionalism and ethics. They state that:

'Professionalism is a concept that informs how we ought to act, and as such belongs firmly in the realm of ethics. Ideas of how we must act serve as a counterpoint to this. What we must do is set out in regulation and law. This is an important distinction; the compulsion to act morally is driven from an internalised set of moral rules, and can in all meaningful ways be considered voluntary. It is an 'ought' action. The compulsion to act legally is driven by the threat of sanction and punishment. This is the 'must' action.' 4

There are several problems with this passage. First, it is unclear exactly how much professionalism as a concept can tell us about how we ought to act when the various definitions of the term are so amorphous. Second, the proposed distinction between 'ought' and 'must' is fallacious. Many would argue the contrary: that ethics tells us what we must do in a given situation, and that the law tells us what we ought to do generally. We can certainly sometimes say that a particular law is unethical; according to Trathen and Gallagher this means that we ought not to do that which we must do. Third, if we are looking to guidelines for our definition of professionalism, and what we must do is set by regulation and law, is professionalism not a question of must rather than ought according to their own definition? If the GDC is going to sanction those who don't meet its definition of professionalism, then we are clearly in the realm of 'must' as defined by Trathen and Gallagher.

In fact, although moral relativism held sway for much of the twentieth century, there is almost always a best ethical solution to a problem, and we must aim for such resolution of dilemmas, despite the fact that the best course of action is often hard to find. To speak of ethics as the realm of 'ought' implies that you don't really have to do it if you don't want to, which is misleading in the extreme and itself implies a lack of professionalism. Trathen and Gallagher state that 'the “ought” represents the constant attempt to achieve more than is required: to realise our potentials. This is a concept which gets to the heart of professionalism – striving for the best when there are no external forces compelling you to do so.' As already stated, this is doubly wrong: first, doing what is best is an ethical requirement, not an optional extra: second, it is very clear that the GDC is compelling dentists to be as professional as they possibly can, even if only severe unprofessional behaviour will trigger fitness to practise proceedings.

Ethics for undergraduates

As already stated, it is impossible to be unprofessional without being unethical: I would suggest that the GDC's increasing emphasis on professionalism as an abstract concept rather than a concrete standard is unhelpful and ultimately confusing, and that the focus should shift to facilitating the learning and assessment of ethics within the dental curriculum. The three main 'ways' of being ethical are obeying rules (deontology), maximising benefit (utilitarianism) and being virtuous (virtue ethics). Inculcating virtues in BDS students is very much uncharted territory, and it may be that students are too old and set in their ways to really acquire new virtues. (On the other hand, Plato believed that the maturity required to study philosophy was not attained until the age of 30.) Nonetheless, this is exactly what would have to be done if we were to take seriously Trathen's and Gallagher's RCP definition and the GDC's emphasis on trustworthiness. It seems more realistic to have students learn about particular rules, and learn how to analyse and deal with ethical problems on a logical benefit-maximising basis; in other words, provide them with the moral perception and ethical skill-set to deal with ethical problems as they arise. To this end, undergraduate BDS students at the University of Glasgow participate in a series of small-group ethics workshops where they discuss and analyse case studies and decide on the most ethical course of action. Their ethical skills are assessed in various formative and summative assignments as well as multiple short answer essay questions; the assessment of ethics is now being extended to objective structured clinical examinations (OSCEs).

In parallel with learning about ethics, it is essential that dental schools continue to monitor students for any unethical (or unprofessional) behaviour. If it is made clear to students that turning up late for clinic is unethical because it inconveniences patients, that talking about patients in lifts is unethical because it breaches their confidentiality, and that even talking in the library harms people indirectly, they will come to realise that all their actions have consequences, and that they must reflect on and act to change these consequences if they are having a negative effect on others. That, I would suggest, is what many of us actually mean when we speak of professionalism: being ethical.

New definitions

Ultimately, I would offer the following definitions. Being (a) professional means meeting the standards of the profession, whatever those may be (just as the GDC's definition of the purpose of undergraduate dental education is 'to produce a dentist who has demonstrated, on graduation, that he or she has met the outcomes required for registration with the GDC'.1) Being unfit to practise means that one has breached those standards and been unprofessional to such an extent that one can no longer be allowed to practise. Being ethical means being professional and being able to deal with morally perplexing situations.

Being a professional means doing what the GDC says. But the GDC will never give advice on how to solve particular ethical problems; in this sense, ethics is actually outwith the dictates of the profession. A dentist is unlikely to be detected for ethical lapses unless they also breach a guideline or law, but exemplary ethical conduct goes beyond the minimums imposed by guidelines. Trathen and Gallagher assert that 'This is a concept which gets to the heart of professionalism – striving for the best when there are no external forces compelling you to do so',4 but this is actually a definition much more suited to ethics: obeying the ethical imperative to go beyond merely meeting professional standards and maximise benefit to patients. Trathen and Gallagher are right that guidelines and laws set the minimum standard, but wrong to say that the professional strives to go further: the professional is defined as such by his meeting certain formal criteria, and anything beyond that is in the realm of the ethical.

To put it differently: to be a dentist you have to meet certain professional standards. To be an ethical dentist, you must go further. Just as supererogatory action goes beyond that which is ethically mandatory, so the ethical dentist goes beyond the merely professional.6 If you are a registered dentist, then by definition you are a professional; any talk of professionalism beyond this point risks the illogical paradox of the unprofessional professional who is quite unprofessional but remains a professional because he isn't bad enough to be struck off. A dentist can certainly be unprofessional by being unethical, just as he can be unprofessional by being bad at communication or clinically inept. But he can also be slightly unethical and remain a professional; this is why ethics is the higher standard.

As mentioned earlier, a dentist can be unprofessional in many different ways: lack of communication skills, clinical incompetence, or alcohol abuse. He can also be unprofessional inasmuch as he is unethical, for example by routinely failing to respect his patients' autonomy. But any and all failures in professionalism are unethical because they increase the risk of harm to the patient. Thus ethics is both an area where a dentist can be in breach of professional guidelines, and the domain from which we can criticise all breaches of professionalism.

Conclusion

It has been suggested that a greater emphasis on professionalism is needed within dental education and the profession at large. This paper has argued that greater clarity is needed in discussing professionalism, ethics and fitness to practise, and that ethics education is both more important than professionalism, and easier to assess. It is simply unethical for a dentist to fall behind current clinical practice, or to be bad at communicating, or to fail to interact well with colleagues and patients. All of these unprofessional behaviours can harm patients, and ethics is about maximising benefit and reducing harm. Providing dental students with the means to detect the ethically relevant features of a situation and act in an ethically reflective manner will produce dentists who are as professional as they can be.