ISSN 0798 1015

Vol. 39 (Number 41) Year 2018 • Page 23

Ethics and Bioethics as a research topic in dentistry: a gap in the scientific knowledge

Ética e Bioética como tema de investigação na Odontologia: uma lacuna no conhecimento científico

Mariáh Macedo REBELLO 1; Doris GOMES 2; Mirelle FINKLER 3

Received: 13/04/2018 • Approved: 28/05/2018

Content

1. Introduction

2. Methodology

3. Results

4. Discussion

5. Conclusions

Bibliographic references

1. Introduction

The etymological conception of the word profession stems from the action of "professing" which means one's willingness to express an important statement. The first profession of doctors, clerics and lawyers represented a divine vocation originally separating them from the remaining of the society. With the advent of the scientific and industrial revolution in the eighteenth and nineteenth centuries, the term profession took on a new connotation related to employment, such as professional occupation and/or service. However, in order for this new social division of labor to achieve professional status, a complex process of social recognition related to the relevance of practices in society became necessary, built through training in educational, production, scientific publication and ethical accountability systems (Rule y Veatch, 2004, Gracia, 2004). 

In this context, the creation of so-called "codes of ethics" is considered one of the most important sociological attributes in the definition of the profession. Such ethical regulations should foster a critical and reflective professional practice, based on guiding values of the relationship between professionals and society. However, they are often focused on professionals and not on patients (corporatism nature) (Pyrrho, Prado, Cordon, y Garrafa, 2009). They determine rules previously established by the professional bodies (generalist) and their respective penalties (legalistic nature), usually without an ethical foundation (reductionist nature to conceive ethics as the pursuit for the right). Still, the ethical codes were used as a basis for ethics education in dentistry for decades. It is not surprising, that despite the continued emphasis on dental ethics education (Odom, Beemsterboer, Pate, y Haden, 2000) the impact of our ethics curricula on the students should be regarded as minimal: "our ethics courses are inadequate in content and form to the extent that they do not cultivate an introspective orientation to one's professional life... no one’s behavior changes as a result” (Bertolami, 2004).

The daily corruption practiced by health professionals is growing and undeniable, especially when the medicalization of life and the incorporation of high technology in the therapeutic processes have assumed consumption and marketing characteristics (Hortal, 2000, Gomes y Ramos, 2014). In Dentistry, there are many reported cases which include ethical issues related not only to the professional daily exercise, but also vocational training (Rule y Veatch, 2004, Bertolami, 2004, Chattopadhyay, 2013, McCabe, 2001, Finkler, Caetano, y Ramos, 2011, 2014). In addition, consistent problems in universal health systems such as in Brazil (SUS), in the context of deep economic-social and cultural disparity, place ethics/bioethics beyond interpersonal relationships. Is it to answer questions such as: Are dentists able to build dialogic relationships with their patients and communities? Do they participate in the collective deliberation forums that exist in SUS? Are they eligible for a co-managed oral health team job? Do they involve with the oral health situation of vulnerable populations? Dentistry is challenged to build new dialogical, democratic and citizen relations, strengthened in values such as solidarity and justice (Gomes, y Ramos, 2014).

Facing these problems, and as an alternative to the traditional teaching of professional ethics, bioethics emerges as a theoretical and methodological reference able to contribute to the necessary education. Education, whose objective is to search for autonomy, responsibility and deliberation among all subjects, makes them, moving from heteronomous and autonomous subjects, from obedient people to critical and mature citizens, able to lead themselves morally. Therefore, it is not about solely teaching bioethics, but employing it as an instrument for training values (Gracia, 2014).

Assuming that scientific and academic production provide feedback and reflect each other, the aim of this study was to analyze the dental scientific production related to ethics and bioethics in the last 16 years. Knowing such production can give us clues about the quality of the ethical dimension of vocational training that is being held. It may help one to analyze whether the extraordinary technical and scientific progress of dentistry has been ethically grounded. And can ultimately help us to reflect on the social responsibility of the university: to identify health problems and drive teaching and research for impact actions that enable better living conditions in society.

2. Methodology

Bibliometrics was used as method to know the state of the art scientific production of ethics and bioethics in Dentistry. As a result, this type of quantitative methodology provides a panorama of the knowledge body in a given scenario and time frame. It basically consists in analyzing a sample of secondary data from indexed journals, conference proceedings and other bibliographic document sources related to scientific production. It allows data variables such as subject, authors, research groups and institutions to comply with information related to the progress and the state of the art of a particular topic (De Bellis, 2009, Thompson Reuters, 2008).

“IADR Abstracts Archive” database, available at International Association for Dental Research (IADR) website was used for this research. This is because this Association constitutes a nonprofit organization with almost 11,000 members worldwide, reflecting the scientific production in the field of dentistry, at the international level. The base currently has 86,283 abstracts of researches published, workshops presented and symposiums held since 2001 in the proceedings of their events and events of the affiliated associations (International Association for Dental Reasearch, 2018a).

The sample was comprised of the abstracts published in the proceedings of the IADR General Sessions, as it is the greatest scientific research dental event, with participation from 4 to 6 thousand researchers in each edition (International Association for Dental Reasearch, 2018b). The period of analysis was determined according to the first event (2001) whose abstracts were available online since the start of data collection until 2016 (International Association for Dental Reasearch, 2018a), thus totalizing 16 years. In this period, eight General Sessions were held in the USA and the rest in other countries. It can be concluded that even though researchers are from different countries, most of them should be American.

During data collection, the search platform has been modified, changing the searches from word or word fragments by only keywords. Thus, data collection from 2001 to 2013 was performed using the fragment "ethic”; and data collection for the years 2014 to 2016 was performed using the keywords suggested by the website containing the fragment "ethic" (Ethics; Ethical Issues; Ethic &amp, law; Dental Ethics; and Bioethics). To preserve the methodological rigor of the data collection, to facilitate comparisons between them, and to keep the wealth of data collected in the search for fragments, the search for keywords was also carried out between 2001 and 2013.

The developed protocol followed a three-step sequence:

At the Phase I (P-I) data was accessed on the aforementioned base, separately for each of the 16 General Sessions of the IADR, as the searches explained above.

In Phase II (PII) initial data were submitted to the inclusion criteria (thematic on ethics and /or bioethics) and exclusion criteria (search titles without abstract and abstracts with irrelevant content to the theme, such as works which were solely submitted for approval by a committee of research ethics).

In Phase III (PIII) the included abstracts were read by three researchers (two graduate students and a professor expert in the subject). From this first reading, the researchers decided on the themes that emerge from the perceived data, namely: Research and Scientific Publication, Professional Education, Bioethics Teaching, Bioethic Themes, Deontology, Public Health. The abstracts were then read again and classified in those thematic categories.

3. Results

A total of 357 abstracts were identified in searches for snippets during PI and 26 abstracts in the keyword search. In PII, 344 abstracts were excluded, and 32 abstracts were included in the research (Figure 1), corresponding to .059% of the total (54,115) abstracts published in the analyzed period.

Figure 1
Results of the methodological process of composition of the sample by event, location and year.

The results obtained by PIII are shown in Figure 2, detailing the titles of the abstracts and their respective years of publication. There has been a concentration of researches where ethics and/ or bioethics were linked to research questions and scientific publications (13 abstracts).

Figure 2
Abstract titles and year of publication by thematic categories/total of abstracts.

Figure 3 shows the number of abstracts published annually, showing a significant fluctuation without denoting increasing or decreasing bias over the period investigated.

Figure 3
Variation in the number of abstracts published over the period examined.

4. Discussion

The results showed that dental research has attributed little value to ethics and bioethics. This is a disturbing result. Unsurprisingly dental research is predominantly geared towards life sciences, for developing materials and techniques with little social impact, with a predominance of laboratory studies and clinical trials of individualized nature (Finkler, Calvo, Caetano, y Ramos, 2009, Finkler y Verdi, 2014). The need for science and humanities, technical and ethical, is not new either, as pointed out by Potter in the 1970’s with his original concept of bioethics. “His attention to the creation of human knowledge and incorporation of ecological concepts and values into medicine and health remain important, yet largely neglected” (Whitehouse, 2003, p. 26).

Originated by a social-cultural movement, bioethics became an academic discipline, when embracing the ethical issues applied in the healthcare field, seeking to contribute to the pursuit of prudent responses to the conflicts constantly present in the relationship between patients, professionals, science, State or environment. Its role in this century, considered by many to be the biotech century, is to be an important instrument of ethical reflection that, among other demands, gives researchers and society enough information to take a critical position regarding the fulfillment of scientific research (Finkler y Verdi, 2014). But Dentistry, according to the results presented here, seems to remain somewhat undercommitted to this international agenda. This agenda that is worth remembering, was agreed between UNESCO member states through the Universal Declaration on Bioethics and Human Rights, adopted by acclamation at the General Conference in 2005 (United Nations Educational, Scientific and Cultural Organization, 2018).

Set away from the human sciences and its reflective knowledge, the biological sciences with their empirical knowledge lost its perception ability, self-criticism, and the ability to generate meaning to its very practices. The exceptional technical and scientific development over the last decades made us believe that its value is unquestionable, raising science to a level of an intrinsic value, when in fact, it has only an extrinsic value, an instrumental value.

The history of the twentieth century is full of examples of which, in terms of science, not everything that we do, we must do. It is the (bio) ethics reflection that makes us this alert. Why do we research what we research in Dentistry? What should be the profile of the dentist for working in universal health systems, such as SUS? What are the values that we give priority to in these elections? How do these choices influence the levels of health and disease in populations? What are our responsibilities over the consequences of these options?

Although the focus given to the scientific production can be understood by the direction taken in the historical building of the profession, there are unavoidable reflections on the adjustment of production to the academic and professional performance to local circumstances of health and life quality.17 One has to think for what and whom a technically laudable Dentistry would serve, if it does not impact epidemiological indices of oral diseases. It is necessary to reflect on the focus of scientific discoveries as a common good or a privilege for some: being scientific progress a conquest of mankind, its results should benefit everyone and not just those who hold the monopoly of the results in the advancement of science (Garrafa y Moysés, 1996).

Such questions arise from a critical-reflective, deliberative rationale that this is the path through which bioethics proposes making prudent decisions in uncertain situations, typical of ethical problems. Unlike what happened in its first 40 years of existence, when it was very accustomed to dramatic, generally individual situations, "Bioethics 2.0" focuses on issues that affect the society as a whole (Gracia, 2014). As a subject in undergraduate courses in the health area, it is designed to develop students' attitudes (Gracia, 2004), in contrast to most of the disciplines of Dentistry courses that emphasize cognitive (knowledge) and psychomotor (skills) learning. By this potential, an increase in the number of dental research on bioethical issues as well as on the teaching of this discipline is expected.

The categorization of abstracts with themes related to ethics / bioethics revealed a concentration of papers on the theme "research and scientific publication”. The selection of preferably independent research subjects and their protection, the balance of risks and benefits for the research subjects, obtaining their consent, the guarantee of confidentiality and privacy, respect for vulnerable populations, rigor in the methodological design, the committees of research ethics, and some conflicts of interest are the most commonly found issues when one reviews the dental literature (Finkler y Verdi, 2014). Thus, the result shown in this study is not surprising. Rather, it was expected, since abstracts are from a researching society, and more because they included not only abstracts of research, but also from symposia and workshops. In fact, 7 out of the 11 abstracts included in this category were related to the latter two types of activities (6 symposia and 1 workshop). It should be noted therefore the IADR's efforts to promote the issue of ethics in scientific production in the various editions of its events.

About the categorization performed, it is worth highlighting that the six themes that emerged from the data reveal the different approaches that have been given to ethics in Dentistry, even though this division is more of an analytical theoretical effort than a formal division. Deontology or professional ethics, bioethics and its teaching, other ethical issues in education, ethics in research and scientific publication, and ethics in public health are issues that hold somewhat close relations, depending on the references that are adopted as fundamentals.

It is known that the perception of students and teachers of ethics in Dentistry is often associated with ethical notions of ethical and legal bases, not having a broader conception of the ethical dimension of vocational training (Thompson Reuters, 2008). A reality pointing to the need for changes in Dentistry teaching, in the sense that students can effectively overcome the condition of being passive learners toward a level of critical thinkers, getting ready for the reality of professional life and for dealing with problems that arise in that relationship (Rule y Veatch, 2004).

A study on the awareness of college students on issues related to poverty and inequities of access to health services presented results which supported the idea of the need to develop this approach with dental students (Reis, Rodrigues, Macaulay, y Bedos, 2014). This is because the individual-liberal action still remains a social and professional image-representation of success in Dentistry and may be considered the cause and effect of the stereotype of the profession, as well as its deriving social charges, from the professional models more or less valued in the professional socialization and the educational formation - a fictional statement that affects vocational training. The management of more sophisticated technical tools that add market value associated with an overvaluation of technology, depreciates the work in the areas of knowledge considered "human" that emphasize social and collective rights of democracy and solidarity values (United Nations Educational, Scientific and Cultural Organization, 2018). The reflection of this reality can be perceived globally through epidemiological indices related to oral health, evidencing the strong inequality of access to dental services which still exists, even in developed countries, and the least connotation associated with collective oral health than other fields of Dentistry (Finkler, Calvo, Caetano, y Ramos, 2009).

The analysis of floating distribution of abstracts over the period assessed did not show any tendency to increase. It is necessary for the researchers, mostly professors and graduate students, to have knowledge about these results to rethink the investigative practices in Dentistry. It is because scientific research is the protagonist in academia and this role greatly influences the formation and professional practice that is not ethically justified unless to meet the demands of society. Thus, the responsibility implied in the election of the themes of scientific research assumes a core importance that ultimately affects individuals and collectivities.

In fact, this lack of scientific production is reflected in how current studies demonstrate that the development of the ethical dimension in dentistry is still precarious and ineffective.  The recurring aspect of delegating responsibility for ethical development of students to the teaching of the code of ethics contributes to this. Current literature data demonstrate that although the students report that they are encouraged (informally) to make a constant reflection on their clinical practice, there is no formal activity that allows, in a didactic and specific way, development the ability of self-reflection (Jonas Dwayer, Abbott, y Boyd, 2014). 

Despite the recognition of ethics as fundamental in modern dental training, it is still necessary for discipline to gain greater emphasis, both in the pedagogical aspect and in the cultural aspect of valuing this dimension within the profession. It is important for dentistry to develop dynamic methods for improving the reflective reasoning around moral aspects. Nonetheless, the cultural shift of the profession which overestimates technical skills to the detriment of human, psychological and behavioral skills, it focuses on the dentist and not on the patient, and thus cannot significantly influence epidemiological indicators of oral health worldwide. So far, research on dental ethics does not seem significant enough to reflect in undergraduate training students being able to influencing on the next dentist`s generation (Patrick, 2016).

5. Conclusions

The presence of ethics and bioethics as issues of dental research is minimal and it is not possible to observe a tendency to its increase. But if quantitatively there is a negligible production, the same cannot be said qualitatively, by the importance and variety of the researched themes, although there is an emphasis of the issues related to the research and scientific publication. There is, therefore, a big gap in this area of scientific knowledge production, which may have repercussions both in academic as well as in performance of dental professionals, especially with regard to the social commitments as a profession in the area of human health.

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1. DDS, MSD - Dental Public Health. mariahrebello@hotmail.com

2. DDS, MSD, PhD Nursing Sciences, PhD Student Dental Public Health. dorisgomesodonto@gmail.com

3. DDS, MSD, PhD Dental Public Health. Professor at Universidade Federal de Santa Catarina/ Brazil. mirelle.finkler@ufsc.com.br