Decision-making in the face of bioethical conflict and training in Dentistry

Abstract

This study aims to understand the relationship between conceptions of ethics and decision making in situations of bioethical conflict in practices of first-year dentistry students. Holistic case study with a qualitative approach was carried out, in two steps: in the first, 62 participants answered an online form with two questions about conceptions of ethics; in the second, 59 deliberated on two health situations with bioethical conflict. Discursive textual analysis was performed. Results show that students understand ethics as individual guidance in social and profession conduct. In training, students’ restricted conceptions of ethics are amplified in the decision-making exercises in the face of bioethical conflicts. The role of singular contexts is an element for the decision-making in learning that includes respect for life and not just the treatment of disease. The topic of bioethics, thus transversalized in the formative process, values people-centered care.

Ethical analysis; Education, higher; Ethics, dental; Clinical decision-making

Resumo

O objetivo deste estudo é relacionar concepções sobre ética com a capacidade de tomada de decisão de estudantes no estágio inicial do curso de odontologia. Trata-se de pesquisa qualitativa, dividida em duas etapas: na primeira, 62 participantes responderam a um formulário on-line com duas perguntas sobre concepções de ética; na segunda, 59 deliberaram sobre duas situações de saúde envolvendo conflitos bioéticos. As respostas passaram por análise textual discursiva, por meio da qual se verificou que a maioria dos estudantes compreende a ética como orientação individual nas condutas sociais e profissionais. Essa concepção restrita de ética aparece também nos exercícios de tomada de decisão. Conclui-se que o ensino de bioética deve contemplar o papel de contextos singulares na tomada de decisão, enfatizando o respeito à vida, e não apenas o tratamento de doenças. Tal ensino, inserido de maneira transversal na formação, valoriza o cuidado centrado nas pessoas.

Análise ética; Educação superior; Ética odontológica; Tomada de decisão clínica

Resumen

El objetivo de este estudio es relacionar concepciones sobre ética con la capacidad de toma de decisiones de estudiantes en la etapa inicial del curso de odontología. Se trata de una investigación cualitativa, dividida en dos etapas: en la primera, 62 participantes respondieron a un formulario en línea con dos preguntas sobre concepciones de ética; en la segunda, 59 participantes deliberaron sobre dos situaciones de salud que implican conflictos bioéticos. Las respuestas se sometieron a un análisis textual discursivo, por medio del cual se constató que la mayoría de los estudiantes comprende la ética como una orientación individual en las conductas sociales y profesionales. Esta concepción restringida de la ética aparece también en los ejercicios de toma de decisiones. Se concluye que la enseñanza de la bioética debe contemplar el papel de los contextos singulares en la toma de decisiones, haciendo hincapié en el respeto por la vida, y no solo en el tratamiento de enfermedades. Tal enseñanza, inserida de manera transversal en la formación, valoriza el cuidado centrado en las personas.

Análisis ético; Educación superior; Ética odontológica; Toma de decisiones clínicas

Bioethics analyzes how people’s lives can be affected by scientific and technological development in the health area. Its application includes individual or collective deliberations on the use of technologies that involve life, being linked to the very meaning of humanity ¹. The analysis of singular cases, associated with philosophical models, supports bioethical reflection. This casuistic analysis paradigm starts from the particular circumstances of a case to detect the ethical core of the situation. In decision-making, to face conflicts, primary bioethical principles emerge, such as autonomy, beneficence, non-maleficence, justice, and other derivatives (fidelity, truthfulness and confidentiality) ¹,².

Critical analyzes of the deontological codes, responsible for guiding professional conduct in therapeutic procedures, have shown that these documents favor professional protection, highligthing corporate attitudes based on prescriptions to resolve ethical conflicts ³,⁴. Quality of care, however, is related to the professional’s bioethical competence. Self-judgment or intuition alone cannot substantiate choices; they must be associated with a foundation and ethical studies. The ability to decide presupposes moral responsibility for choices. The dynamic nature of events testifies against formulas or rules of action. The ethical judgment will depend on the analysis of the reality in question ²,⁵,⁶.

Health education transcends metrics of diagnosis, therapy, treatment, prognosis, etiology and prophylaxis of diseases and conditions, as it encompasses skills and abilities that allow professionals to understand the people’s needs in their social contexts. Thus, building and agreeing on therapeutic projects that encourage co-responsibility presupposes the humanization of care ⁷ – understanding “human,” here, not as a conquest of reason, but as a value that resides in the individual’s relations with their own history, culture and society ⁸.

Considering health education, a question guides the present study: when exposed to professional situations that require decision-making, how do students deal with ethical concepts shaped by their social and family realities? First-year undergraduate Dentistry students participated in the research. Based on their statements, the study intends to understand and propose processes for teaching bioethics in professional health education.

Method

The article presents results of a qualitative holistic case study, that is, focused on analyzing the phenomenon as a whole, and not the particularities of the cases ⁹. The sample consisted of students from a federal university in southern Brazil enrolled in the bioethics discipline taught in first semester of the Dentistry course. Data collection took place in 2018 and included one morning class (40 students) and one evening class (23 students). All 63 students were invited to participate.

Data collection was divided into two stages. Sixty-two students participated in the first stage, in August 2018, and answered an online form with two open questions: “What is ethics for you?” and “How do you see the importance of ethics in Dentistry?” Fifty-nine students (36 from morning classes and 23 from evening classes) participated in the second stage, in September 2018. Two situations were presented, proposed and analyzed in Zoboli ⁶ (Chart 1). Participants were asked to put themselves in a health professional role and describe the behavior they would adopt in these situations. The objective was to understand how the primary principles of bioethics (autonomy, beneficence, non-maleficence and justice) would be used by students in decision-making in the face of bioethical conflicts.

Chart 1
Possible situations of bioethical conflict according to the Zoboli 6 intervention matrix

Preserving confidentiality (36 morning-class students responded)	Mr. M has syphilis. He doesn’t want to tell his wife what he has, but he wants to protect her from the disease. While in treatment, M asks that his wife be tested for syphilis without her knowledge.
Assisting adolescents (23 evening-class students responded)	B, 15 years old, shows up at the basic health unit and says that she recently fell in love with a 16-year-old boy. Her parents think she is too young and forbid her to date. The adolescent says she does not have an active sex life yet, but asks for a prescription for oral contraceptives. She also asks that nothing be told to her parents.

Students’ responses were examined by discursive textual analysis, divided into the following procedures: pre-analysis, exploratory study and interpretation of information produced from coding and grouping the statements into units of analysis ¹⁰. Participants signed an informed consent form. To guarantee the students’ confidentiality, the statements were coded with the letter “E” followed by a number.

Results and discussion

From individual bioethics to social bioethics

The objective of bioethics can be characterized as the development of empathy and solidarity in people who provide health care. When proposing dialogues with health sciences and technologies, bioethics humanizes assistance and opens possibilities for professionals to understand the reasons for their own decisions ¹¹,¹². However, the analysis of statements of first-year Dentistry undergraduates shows difficulties in discerning the concept of bioethics from that of morals. The definition is often abstract, as reported by Lima and Souza ¹³.

“[Bioethics] is a set of rules and concepts that aim to value each individual’s morality and individuality” (E54).

“It is a set of ‘rules’ that are not imposed in the Constitution, but which are practiced by most human beings. We know that it is not allowed to go to work in slippers, for example, as this action is considered unethical, inappropriate for this place”(E28).

“It is the principles that guide, discipline/educate, motivate human behavior. It is consent between what is right and what is wrong for each case/occurrence/human being” (E58).

Students understand ethics as guiding actions, for the benefit of both the individual and the society. The statements value a conception of ethics centered on the individual orientation to social behaviors. To a certain extent, students are aware – probably even before studying bioethics – of the importance of ethics as a tool that guides decision-making.

“I believe that ethics is a set of principles that should be present in every citizen, in search for a more just and dignified society. Based on the individuals’ ethical thought, some values such as respect and responsibility are perpetuated in the environment, contributing to a more accessible and pleasant space for everyone who lives there. Ethics is also important when making the right decisions and is often used as a tool to judge right and wrong, resulting in justice. But, above all, I believe that ethics is essential to make society properly developed in human relations” (E5).

“Ethics is my principles, my behavior towards others, my behavior towards anyone and, in this case, towards my future patients. Ethics is not law. As much as there are ethical principles for certain professions, there are people who follow them and people who do not. It is something much more personal and that must be built for the good of society” (E16).

“Ethics is the set of principles based on the cultural and historical values of a society, which aims to guide our conduct within society as participants in it, both in our collective and individual actions” (E31).

The statements value the importance of ethics in professional training but remain in the theoretical sphere, detached from the possibilities of applying the concepts to practical situations of health work. These more abstract conceptions may be insufficient in view of the complexity and demands of everyday life. Therefore, classes on bioethics, regardless of the professional area, face the challenge of problematizing such concepts, approaching professional practices and thinking about major themes and current dynamics.

The approach to bioethical topics in health courses can be experienced as a hypercritical but abstract experience or it can expand political action, in a constant scrutiny of what is said, thought, and done ¹⁴. In this last option, it is possible to deal with issues that go beyond “behaving well professionally,” reaching a reflection on the ethical experience in decision-making ¹⁵.

Bioethics in training and professional practice

Health models and practices traditionally focused on the biomedical view objectify practices ¹³. However, although in Dentistry the technique is central, the service should not be based solely on the excellence of the technique, but also on the recognition and understanding of the patient’s needs. As health care, dental practice is established in intersubjectivity relationships. Approaches focused only on technical aspects are insufficient to promote professional responsibility for people’s quality of life ¹⁶. In this sense, bioethics draws the professionals’ attention to dilemmas that the patient faces in their daily life.

Ethical values are a constitutive part of the action, since they guide it, and that is the reason why health practices are related to bioethics ¹⁷. In this perspective, opposed to deontology (constituted as a branch that understands ethics as a moral duty), values come before action. Deontology focuses on “doing what is right,” compliance with a code and professional “good behavior,” limiting ethical conflicts to interpersonal, technical or even legal issues ¹⁸.

The participants’ statements highlight the relationship between individual training and professional conduct, a trend also observed by Lima and Souza ¹³. For students, the ethical professional must have a sense of fairness and commitment to colleagues and patients.

“I see ethics in dentistry as a crucial factor for the performance of this profession, as ethical conduct is basic for professionals who deal with people on a daily basis. Health is an inherent right of any citizen. If a dental surgeon presents any conduct that violates ethics, discriminating against any individual, whether due to social class, race or sexual orientation, this professional is impeding the most basic human right, health care” (E6).

“In all professions, the professional has to be extremely responsible. In the case of Dentistry, it is not different. A dentist should always put their principles ahead of everything else and keep in mind that is dealing with other human beings. Ethics transforms you into a competent and sensible professional, always respecting both the patient and the co-worker, thus being not only a quality dentist, but also a better human being” (E7).

“A professional trained in Dentistry has to comply with ethics to be a good professional, with both the patients and the co-workers. Professional ethics involves solidarity and commitment to others, in addition to respect, which is very important in any profession” (E11).

“For me, ethics is one of the most important things in any profession, but mainly for the health area, in which we are dealing with people, lives and feelings. Much more important than manual skill, ethics relates to care of my patients, not only mechanical care, but humanizing them, the way it should be. Not treating them robotically, but considering all the angles, fears and desires that human beings carry with them. (…) The patient is not just a customer, but – and above all – a person, who deserves to be treated with respect and dignity. In face of the country full of inequality in which we live, ethical values are essential for dental care to be complete and accessible to all realities, promoting quality of life and well-being for different segments of the population” (E27).

“In order for us to have a good relationship with colleagues and patients in the profession, it is necessary to have ethics – a set of actions related to personal values and imposed by society on an individual – with regard to […] treating someone. As an example, we have professional secrecy” (E30).

First-year Dentistry students are not expected to have sufficient grounds to resolve bioethical conflicts ¹⁷. However, the scenario could be better if more than just 31.3% of Dentistry courses in Brazil had bioethics as a mandatory discipline, according to data from 2007 and 2008 ¹¹. In addition, Brazilian research regarding bioethics in Dentistry is still scarce ¹⁹.

An ethical-political engagement stance can be stimulated by a training environment that continually questions attitudes ²⁰-²². When learning about health social determinants, the student becomes able to look at illness situations beyond the clinical perspective, developing empathy for the patient who faces a series of difficulties in accessing the health system. Bioethics exposes what is seen, but not perceived.

In Dentistry courses, bioethics develops values related to the care for the person ²³,²⁴, allowing students to get in touch with experiences of ethical conflict and expand practical and theoretical knowledge that will be important in their professional trajectory. Bioethical themes can be discussed at all times in the curriculum, in a transversal manner. These themes must accompany the students’ involvement in clinical practice, increasing, almost naturally, the student’s sensitivity to subjective and social aspects of the relationship with the patient.

Deliberation and decision-making: values in bioethical conflicts

According to Zoboli ⁶, for the situation “Preserving confidentiality” (Chart 1), the possible courses of action fall between two extremes: either the truthfulness of the clinical relationship is sacrificed, by lying to the wife, or the husband’s confidentiality and privacy are respected. Chart 2 presents the categorization of the participants’ responses, comparing them with the courses of action found in the work of Zoboli ⁶.

Chart 2
Dentistry students’ responses to the situation “Preserving confidentiality,” classified according to courses of action proposed by Zoboli 6

Zoboli Classification 6	Courses of action	Responses (n=36)
A	Request that the wife be tested for syphilis only after the husband tells her the truth	18
G	The professional must tell the wife	7
X *	Refer the case to another professional	4
J	The professional must refuse to apply the test without consent	2
D	Request tests for the wife without her knowing	2
K	Warn the wife about the disease and request a test, without telling the truth about the husband	2
F	Call the wife to the Basic Health Unit so husband and health professional can inform her about the syphilis and, if she accepts, request the test	1

• * The course of action X does not appear in Zoboli’s study, but was identified in this study.

In view of the bioethical conflict, it appears that the intrinsic value privileged by students was the protection of life. The situation led most students to choose intermediate courses of action, a result that is in line with Zoboli’s research ⁶. It is noteworthy that there was a greater diversity of courses of action in the reference study (13) compared to this study (7). It is also necessary to emphasize the difference in the characterization of the samples: in the study by Zoboli ⁶, the participants were physicians and nurses already inserted in professional practice and, therefore, probably with stronger bonds with patients.

In this investigation, most students adhered to the extreme honesty and valuation of the wife (Figure 1). The sample composition, with more women (72.6%), can explain this result, which indicates an aspect of gender representativeness in the bioethical deliberation.

Figure 1
Chart 2 explanatory schematic outline

Importantly, no nurse in the study by Zoboli ⁶ opted for the course of action “refer to another professional,” while four Dentistry students chose this alternative. This result may be related to bonds and personal experiences in health services, which are still distant to first-year students.

Regarding the situation “Assisting adolescents,” the two extremes in conflict are: respect for the adolescent’s confidentiality and respect for the parents’ responsibility ⁶. In this situation, most students chose to guide the adolescent on the use of contraceptive methods (Chart 3).

Chart 3
Dentistry students’ responses to the situation “Assisting adolescents,” classified according to courses of action proposed by Zoboli 6.

Zoboli Classification	Courses of action	Responses (n=23)
D	The professional should indicate the condom and talk to the parents	7
B	Explain contraceptive methods and instruct the patient to talk to the parents	6
C	Not to prescribe contraceptives and instruct the adolescent to talk to the parents first	6
A	The professional should indicate the condom and not involve the parents	4

Also in the situation “Assisting adolescents,” the students’ responses indicate a tendency to protect life by understanding and welcoming the patient, considering the complexity of the situation. The health care provided to adolescents, who have parents or other adults responsible for them, is a controversial topic from the bioethical point of view, since it poses challenges in terms of secrecy, confidentiality, and bonds. The professional must try to understand the adolescents’ social and family context in order to solve the dilemmas ²⁵,²⁶.

It was possible to perceive connections between the choices of courses of action and the responses to the questions “What is ethics for you?” and “How do you see the importance of ethics in Dentistry?” The students were especially concerned with the respect for the patient’s rights:

“Every dentist’s action must be based on ethical principles that respect human rights and, therefore, patients. It would not be right, for example, for a dental professional to fail to inform their patient about the risks of a treatment, or else to fail to prioritize their health (…) There must be a lot of ethics involved for a fair and efficient service to be offered to society” (E5).

“Ethics in Dentistry is very relevant because it guides the professional (...) to do the best/right for each patient and in each case, different from each other, (...) always putting health first” (E58).

The students’ preference for intermediate courses of action, in an attempt to respect the values in conflict without prioritizing one of the people involved, may be related to the understanding of the health professional as responsible for maximizing the quality of life:

“Professional ethics involves solidarity and commitment to others, in addition to respect” (E11).

“[Professional ethics is] to foster the values and activities of the profession. It is to do well and not to harm others. It is to act with responsibility, honesty and competence” (E49).

“Ethics is important in Dentistry because our role is to take care of other people’s health and, because it is a great responsibility, our values must guide us to do the best possible for others” (E18).

“I see [ethics] as a supporting pillar to be a great professional. The Dentistry area deals directly with people from different realities, therefore the dentist’s ethical sense knows that the treatment must be the same, regardless of the differences. Ethics is also applied when treating the patient, when communicating, etc.” (E28).

When entering the Dentistry course and before studying bioethics, students have concepts of ethics close to the concept of morals, restricted to the idea that there would be a “right or wrong” solution to conflicts. Some statements analyzed, however, express a greater range of analysis, which combines intercultural understandings with bioethical perception as guiding decision-making:

“[Ethics is a] set of values and ideals that guide the behavior of individuals in all areas in which they are inserted, and it is responsible for the simplest to the most complex decisions. (…) It is necessary to measure the consequences and repercussions that your actions will have on others’ lives and look for the best possible alternative” (E27).

“I believe that in the Dentistry area ethics is important both in the relationship with the patient and in deciding which treatment to perform (…). When it comes to deciding which treatment to perform, ethics are fundamental to really analyze case by case and not simply perform the one that is most practical for the professional” (E46).

“Based on the individuals’ ethical thought, some values such as respect and responsibility are perpetuated in the environment, contributing to a more accessible and pleasant space for everyone who lives there. Ethics is also important when making the right decisions” (E5).

“I believe that ethics is a concept in constant transformation and construction, aiming to adapt to the reality and the context of the moment (...), as it deals with the improvement of coexistence in society, which changes frequently” (E48).

Students use bioethical principles to support decision-making, as seen in a study by Brondani and Rossoff ²⁷.

As for teaching methods, there are ways to address ethical conflicts that facilitate students’ understanding. It is possible, for example, to stage situations that require mediation. Methods like this transform the bioethical debate, traditionally theoretical, into experience ²⁸. The experience of training processes inserted in reality produces knowledge and ensures the continuous and renewing construction of learning. This perception is evidenced in the students’ statements.

Throughout training, the student have to improve qualified listening and verbal and non-verbal communication, developing a “perceptual dimension” that strengthens the professional-patient bond and the construction of therapeutic projects ²⁹. In addition, it is necessary to encourage interdisciplinary ethical dialogue, since the union of professionals reduces dubiousness in decision-making and increases co-participation. Collective deliberation supports critical reflection on events, debate and the search for sensible solutions in the face of ethical conflicts ³⁰.

Final considerations

The study analyzed ethical concepts that students have before entering the Dentistry course, comparing them with the decision-making of these same students in fictitious situations that involve bioethical conflicts. In the responses to the dilemmas presented, the participants showed a tendency to try to balance the conflicting principles, seeking intermediate solutions. Even without clinical experience, students were able to indicate courses of action that contemplate not only assistance and treatment, but also welcoming, care and respect for life.

We conclude that debating topics and concepts of bioethics in undergraduate studies can broaden the understanding of future professionals about how care practices must respect the patient’s rights, also pointing to the importance of the benefits of science being in balance with the demands of production of life. The study of bioethics is potent in developing the awareness with regard to individuals as complex beings, who must be fully cared for, with respect to their beliefs and culture.

The courses of action cannot be limited to applying techniques and protocols, in a perspective that reduces the different situations of the health universe to the moral limits of the deontological codes. In this sense, the participants’ statements in this study confirm the importance of bioethics as a foundation for decision-making that focus on the principles of autonomy, justice, beneficence and non-maleficence.

Referências

• ¹
  Gracia D. Pensar a bioética: metas e desafios. São Paulo: Loyola; 2010.
• ²
  Junges JR. Metodologia da análise ética de casos clínicos. Bioética [Internet]. 2003 [acesso 10 mar 2020];11(1):33-42. Disponível: https://bit.ly/3t4XGtj
  » https://bit.ly/3t4XGtj
• ³
  Monique Pyrrho M, Prado MM, Cordón J, Garrafa V. Análise bioética do Código de Ética Odontológica brasileiro. Ciênc Saúde Coletiva [Internet]. 2009 [acesso 10 mar 2020];14(5):1911-8. DOI: 10.1590/S1413-81232009000500033
• ⁴
  Santos LV, Curi JP, Coltri MV, Faggioni MS, Melani RFH, Arcieri RM, Beaini TL. A evolução do Código de Ética Odontológico brasileiro. Rev Bras Odontol Leg RBOL [Internet]. 2020 [acesso 15 dez 2020];7(2):81-99. DOI: 10.21117/rbol-v7n22020-330
• ⁵
  Armendane GD. Por um cuidado respeitoso. Rev. bioét. (Impr.). [Internet]. 2018 [acesso 10 mar 2020];26(3):343-9. DOI: 10.1590/1983-80422018263253
• ⁶
  Zoboli E. A aplicação da deliberação moral na pesquisa empírica em bioética. Rev Iberoam Bioét [Internet]. 2016 [acesso 10 mar 2020];(2):1-19. DOI: 10.14422/rib.i02.y2016.006
• ⁷
  Warmling CM, Pires FS, Baldisserotto J, Levesque M. Ensino da bioética: avaliação de um objeto virtual de aprendizagem. Rev. bioét. (Impr.). [Internet]. 2016 [acesso 10 mar 2020];24(3):503-14. DOI: 10.1590/1983-80422016243150
• ⁸
  Warmling CM, Fajardo AP, Meyer DE, Bedos C. Práticas sociais de medicalização e humanização no cuidado de mulheres na gestação. Cad Saúde Pública [Internet]. 2018 [acesso 16 dez 2020]; 34(4). DOI: 10.1590/0102-311X00009917
• ⁹
  Yin RK. Estudo de caso, planejamento e métodos. 2ª ed. São Paulo: Bookman; 2001.
• ¹⁰
  Moraes R, Galiazzi MC. Análise textual discursiva: processo reconstrutivo de múltiplas faces. Ciênc Educ [Internet]. 2006 [acesso 1º dez 2020];12(1):117-28. DOI: 10.1590/S1516-73132006000100009
• ¹¹
  Gonçalves PE, Garbin CAS, Garbin AJI, Saliba NA. Análise qualitativa do conteúdo ministrado na disciplina de bioética nas faculdades de odontologia brasileiras. Acta Bioeth [Internet]. 2010 [acesso 10 mar 2020];16(1):70-6. DOI: 10.4067/S1726-569X2010000100010
• ¹²
  Finkler M, Negreiro DP. Formação x educação, deontologia x ética: repensando conceitos, reposicionando docentes. Rev Abeno [Internet]. 2018 [acesso 10 mar 2020];18(2):37-44. DOI: 10.30979/rev.abeno.v18i2.561
• ¹³
  Lima ENA, Souza ECF. Percepção sobre ética e humanização na formação odontológica. Rev Gaúcha Odontol [Internet]. 2010 [acesso 10 mar 2020];58(2):231-8. Disponível: https://bit.ly/3gOb5n3
  » https://bit.ly/3gOb5n3
• ¹⁴
  Veiga-Neto A. Didática e as experiências de sala de aula: uma visão pós-estruturalista. Educação e Realidade [Internet]. 1996 [acesso 10 mar 2020];21(2):161-75. Disponível: https://bit.ly/3vsoFk3
  » https://bit.ly/3vsoFk3
• ¹⁵
  Amorim AG, Souza ECF. Problemas éticos vivenciados por dentistas: dialogando com a bioética para ampliar o olhar sobre o cotidiano da prática profissional. Ciênc Saúde Coletiva [Internet]. 2010 [acesso 10 mar 2020];15(3):869-78. DOI: 10.1590/S1413-81232010000300030
• ¹⁶
  Patrick AC. A review of teaching ethics in the dental curriculum: challenges and future developments. Eur J Dent Educ [Internet]. 2017 [acesso 10 mar 2020];21(4):114-8. DOI: 10.1111/eje.12230
• ¹⁷
  Freitas CHSM. Dilemas no exercício profissional da odontologia: a autonomia em questão. Interface Comun Saúde Educ [Internet]. 2007 [acesso 10 mar 2020];11(21):25-38. DOI: 10.1590/S1414-32832007000100004
• ¹⁸
  Finkler M, Caetano JC, Ramos FRS. Ética e valores na formação profissional em saúde: um estudo de caso. Ciênc Saúde Coletiva [Internet]. 2013 [acesso 10 mar 2020];18(10):3033-42. DOI: 10.1590/S1413-81232013001000028
• ¹⁹
  Marin F, Rebello M, Mello ALSF, Finkler M. Ética e bioética como temas de pesquisa em odontologia: uma análise bibliométrica dos trabalhos apresentados nas reuniões da SBPQO. Rev Abeno [Internet]. 2016 [acesso 10 mar 2020];16(4):51-60. DOI: 10.30979/rev.abeno.v16i4.339
• ²⁰
  Holden ACL. Reflections on the encouragement of altruism in dental education. Eur J Dent Educ [Internet]. 2018 [acesso 10 mar 2020];22(1):198-202. DOI: 10.1111/eje.12247
• ²¹
  Naidoo S. Ethical considerations in community oral health. J Dent Educ [Internet]. 2015 [acesso 10 mar 2020];79(5 Suppl):38-44. Disponível: https://bit.ly/3nrd1mC
  » https://bit.ly/3nrd1mC
• ²²
  Junges JR, Zoboli ELCP. Bioética e saúde coletiva: convergências epistemológicas. Ciênc Saúde Coletiva [Internet]. 2012 [acesso 10 mar 2020];17(4):1049-60. DOI: 10.1590/S1413-81232012000400026
• ²³
  Ardenghi DM. Dentists’ ethical practical knowledge: a critical issue for dental education. Eur J Dent Educ [Internet]. 2009 [acesso 10 mar 2020];13(2):69-72. DOI: 10.1111/j.1600-0579.2009.00575.x
• ²⁴
  Matos MS, Tenório R. Percepção de alunos, professores e usuários acerca da dimensão ética na formação de graduandos de odontologia. Ciênc Saúde Coletiva [Internet]. 2010 [acesso 10 mar 2020];15(2 Supl):3255-64. DOI: 10.1590/S1413-81232010000800031
• ²⁵
  Taquette SR, Vilhena MM, Silva MM, Vale MP. Conflitos éticos no atendimento à saúde de adolescentes. Cad Saúde Pública [Internet]. 2005 [acesso 10 mar 2020];21(6):1717-25. DOI: 10.1590/S0102-311X2005000600019
• ²⁶
  Hertrampf K, Groß D, Karsten G, Wenz HJ. The influence of clinical experience on dental students’ ethical awareness. Eur J Dent Educ [Internet]. 2018 [acesso 10 mar 2020];23(2):101-9. DOI: 10.1111/eje.12408
• ²⁷
  Brondani MA, Rossoff LP. The “hot seat” experience: a multifaceted approach to the teaching of ethics in a dental curriculum. J Dent Educ [Internet]. 2010 [acesso 10 mar 2020];74(11):1220-9. Disponível: https://bit.ly/3xuuS0n
  » https://bit.ly/3xuuS0n
• ²⁸
  Lantz MS, Bebeau MJ, Zarkowski P. The status of ethics teaching and learning in U.S. dental schools. J Dent Educ [Internet]. 2011 [acesso 10 mar 2020];75(10):1295-309. Disponível: https://bit.ly/3xDD2E2
  » https://bit.ly/3xDD2E2
• ²⁹
  Lucander H. An instrument to assess dental students’ competence in shared decision making: a pilot study. J Dent Educ [Internet]. 2017 [acesso 10 mar 2020];81(12):1463-71. DOI: 10.21815/jde.017.108
• ³⁰
  Dalla Nora CR, Zoboli ELCP, Vieira MM. Deliberação ética em saúde: revisão integrativa da literatura. Rev. bioét. (Impr.). [Internet]. 2015 [acesso 10 mar 2020];23(1):114-23. DOI: 10.1590/1983-80422015231052

• Approval Plataforma Brasil 2.522.074

Publication Dates

• Publication in this collection
  6 Sept 2021
• Date of issue
  Apr-Jun 2021

History

• Received
  24 Sept 2019
• Reviewed
  7 Oct 2020
• Accepted
  14 Apr 2021