|[JACD16a: Manuscript – Priming]
Moral Priming and the ACD Basic Rule
David W. Chambers, EdM, MBA, PhD, FACD
James Rest proposed a model of moral behavior with for components: sensitivity, reasoning, character, and courage (or action). Research has shown that moral character is a complex construct. Multiple moral self-concepts exist within each individual, and different context predispose various of these to become dominant in different settings. Moral priming is the practice of manipulating the environment to favor the use of appropriate moral self-concepts. A study is reported, demonstrating that dentists can be primed to express more moral views based entirely on context. The observed effect of priming was large. The ACD Rule for Moral Identity states that when there is conflict between professionalism and economic or other self-interests, professionalism takes precedence. [end of abstract]
Morality is the pattern of actions we use to make the world better: ethics is what we say about that. Unless one is in an academic environment or making a political statement, morality is the more precious of the two. More formally, morality could be defined as the way we treat others who may or may not share our values so that we would feel comfortable exchanging places should circumstances call for that. The definition has these features: (a) there is no presumption that we have a special position based on our superior view of things, (b) we cannot be moral alone; and (c) moral opportunities are pervasive.
It is sometimes helpful to engage in ethical reflection or even justification as part of being moral. But the branch of theory known as virtue ethics (Annas, 2011; Curzer; 2014) has long made a case for the highest form of morality being semi-conscious good habits. Further, it is not enough to have performed a sound ethical analysis, for example based on principles or norms. Aiming accurately is necessary, but the act is incomplete unless we pull the trigger. Morality is about the way we act.
James Rest’s Four Component Model (Rest et al, 1999) helps us find our bearings. On Rest’s view, there are four characteristics of one who would be moral: (a) moral sensitivity, (b) moral reflection, (c) moral integrity, and (d) moral courage. Notice Rest’s preference for the term “moral.”
Moral sensitivity is realizing that one is in a situation with prominent ethical dimensions (Rest, 1986). Unless one realizes that lack of funds or insurance coverage for the most appropriate treatment leads to compromised care, for example, this may remain an economic concern and never reach the moral level. The way a situation is framed, or overlooked, determines the nature of the reflection, engagement, and action that follow. A faux form of moral sensitivity is called “moral awareness” (Reynolds, 2008). There are folks who make a career out of righteous rages against the unfairness almost everyone they meet and society in general, and they are happy to point out that someone else has made of mess of things. Politicians seem to have advanced training in this practice. The difference between moral sensitivity and awareness is that the good one places the observer in the context as an agent. It is only moral sensitivity when the phrase, “this is not right and someone should do something about it,” is understood to mean that the speaker is among the “someones.”
Moral reflection is the second of Rest’s components. That is what we teach in dental schools and short courses. The customary format involves comparing alternatives against principles or norms and deciding what should be done (Beauchamp & Childress, 2009). But reflection may not always be necessary. The domain of ethical dilemmas is not the same as the domain of being a professional. Putting one’s hands where they do not belong, overtreatment, insurance fraud, failing to report child abuse, and substandard care are wrong. There is no second position (or lemma) to be weighed as a plausible alternative in ethical reflection.
Moral integrity, Rest’s third component, also known as moral character, is not about events in the world or about ethical theory. It is about the extent to which we are prepared to act as moral agents (Aquino & Reed, 2002). At the low end of the scale we find “moral spectators.” These are often very sophisticated individuals or organizations, well-tuned to the issues of the day and capable of sustaining an extended ethical discussion at a high level. But they are more like the avid sports fan rather than an actual athlete. At the high end are moral leaders; those who make those around them better, and make a habit of it (Chambers, 2015).
Finally, moral courage refers to what it takes to act on one’s moral sensitivity, reflection, and integrity. It requires both skill and commitment to do the right thing. Perhaps the greatest opportunity to improve the moral capacity of dentists is here. “Moral assertiveness training” might be helpful (Chambers, 2009). We need to develop and practice scripts for confronting those who are not upholding professional ideals and support systems for the many of us who would prefer not to do this alone.
An individual may possess very high levels of moral sensitivity or reflection, and so forth, yet go unnoticed as a positive force for professionalism in dentistry. Our attention would best be focused on the one or two components of morality that are our weakest, as these will usually determine the maximal moral impact we can have. A short test of Rest’s Four Component model, with automatic scoring and guidance for improvement is part of the American College of Dentists online course for dental offices (http://www.dentalethics.org/pead/index-pead.htm).
This paper is about moral integrity. It would be good to have a rule to use when conflicts arise between moral behavior and other values, such as economics and personal satisfaction.
Moral Character Is Situational
An adult’s height is quite stable, but weight, not so much so. Although it is meaningful to speak of a person as being generally agreeable or cynical or good company or not, these dispositions fluctuate depending on circumstances. And the same is true for moral character. The classic study was published by Hugh Hartshorne and Mark May in 1928. Rather than using surveys – and assuming that any one administration of any survey captures one’s “true moral nature” these investigators followed boys for weeks in a variety of settings and observed how they behaved. One would sometimes cheat on a school project, but not when interacting with classmates. Another would cheat in a physically competitive game, but not abstract games of skill. Stealing might be acceptable in the case of a friend’s lunch, but not for school supplies. These patterns varied from boy to boy and were not stable within each child across time.
More contemporary research (Aquino & Reed, 2002; Welsh & Ordóñez 2014) uses questionnaires, but comes to the same conclusion: moral identity is a fuzzy concept and likely to be influenced by circumstances. Some researchers, such as Hinkley and Anderson (1996) and Aquino and his colleagues (2009), argue for multiple dimensions in an individual’s moral outlook. What is “fair” depends on whether, for example, we are talking about one’s self or kin and close friends or about strangers, different “others,” or irresponsible trash. Whether the dress fits is a function of who is wearing it. Others would have multiple moral standards depending on the circumstances. Throughout history, individuals such as Grotius, Jefferson, and Victor Hugo, among others, have argued that stealing is not blameworthy if compelled by necessity, such as being starving. Murder is justified on grounds of self-defense. The classic Harvard study of moral character formation during professional education and the early years in practice (Fischman et al, 2004) revealed that professionals of previous generations were quite aware that circumstances compelled them to “bend the rules” early in their careers – as long as they promised themselves that it was only until they could establish themselves financially.
Each of us has multiple moral personalities. We change them based on circumstances. It is not unusual for parents and neighbors interviewed following a mass shooting to say, “He was always such a nice boy. I can’t believe he would do such a thing.” Victims are usually described as having great potential. Certainly there are dominant moral characters for each of us, and that is what our reputations are built on. There are many moral or immoral personalities that would make us feel guilty or ashamed, and some we simply cannot imagine wearing. How we act in moral situations depends a lot on which of our moral characters shows up for the event. It would be good if we have a rule or some guidance regarding which of our moral selves would be most appropriate in various circumstances.
Can Moral Character Be Influenced?
At first, it may seem a cause for concern to accept that moral character is multiple and that any of us could reasonably be expected to behave differently in different circumstances. On further reflection, this may be a blessing. We have traditionally framed character education as a matter of fundamentally remodeling others. That kind of comprehensive change has proven more than difficult, except in situations such a seminary or the military where almost total control is possible for extended periods of time. Quasi-permanent moral makeovers are possible in gang and prison culture. Certainly, it will be difficult to use moral identity traits that are not widely and conspicuously endorsed among our colleagues even if we have taken the right courses.
A more modest goal than complete moral education, but one that should not be ignored, would be to influence circumstances where agents have an opportunity to be moral. We should invite others to bring forward their better selves. Even when we pass on hoping for radical and permanent changes in character, there is something to be said for improving the moral nature of those around us here and now.
There is some research evidence that this can be accomplished predictably. If that is robustly the case, we might be able to frame a rule to serve as a general guide in dental professional situations.
In the earliest research on this topic, Mazar and colleagues (2008) paid college students serving as research subjects a small amount for each numerical puzzle they solved when given a reasonably large sample of such test sets. Subjects worked alone and turned in their answer sheets to a monitor who did not score the papers, only asking subjects how they scored themselves. Of course, there was potential for over-reporting. The extent of “boosting one’s score” was determined by retrieving the worksheets from a conveniently located trash receptacle subjects were instructed to use, since the worksheets had an identifying code on them. Self-promotion was not huge, but it was very wide-spread.
Mazar thought it would be possible to subtly influence whether an “honest” self or a “slightly self-promoting” self showed up at the desk were the payoff was given. Before beginning to solve the puzzles, some subjects are asked to engage in a neutral task such as listing books read in high school. Others are asked to write down as many of the Ten Commandments as they can recall. We learn two things from such studies: First people cannot recall many of the Ten Commandments. Second, just trying to do so reduces cheating. The effect is called “moral priming.”
Closer to the healthcare setting, priming has been demonstrated for Army medics (Leavitt et al, 2012). These individuals have two identities: military and health care. In this case, rather than measure cheating as the difference between actual and self-reported scores, questions were asked that reflected a disposition to treat others fairly. Ethically ambiguous decisions involved such issues as fixing the dollar amount of compensation to families of soldiers killed in combat versus saving the government money. In one condition, medics completed the ethics questionnaire wearing their uniforms, in a room decorated with military insignia. In the other, they were guided by reporting in scrubs to a room filled with medical equipment. Those primed to activate their medical moral template did in fact demonstrate more moral opinions than the same individuals who could be expected to be thinking of themselves as soldiers.
Demonstrating Moral Priming
Modifying the circumstances to improve the chances the right sort of moral character will be activated is called moral priming. Perhaps we need not do an identity makeover on others. Perhaps it would be a worthy beginning to call out the best character that already exists in them. This would be a more plausible strategy if we could demonstrated that moral priming works in dentistry.
A moral values survey instrument is under development for use in the ACD Gies Ethics Project. This is a 48-item survey, patterned after the widely publicized Moral Factors Questionnaire developed by Johnathan Haight and his colleagues (2012). Embedded within the questionnaire used for this study were three additional items designed to measure pro-moral attitudes or openness to moral behavior: (a) “copayments should not be waived,” (b) “colleagues working below the standard of care should be reported when justified,” and (c) “commercialism undermines dental professionalism.” Experience has shown that there is some range of opinion in the profession on these matters. The items were presented on a five-point Likert scale ranging from 1 = strongly disagree to 5 = strongly agree.
Participants in the study were regents and officers of the American College of Dentists. They completed an identical version of the MFQ survey with three embedded test items on two occasions. The first administration was during the “blue sky” session at the end of the board meeting at the annual convocation in 2015. The second administration was approximately six weeks later, and surveys were returned by mail. A code number, selected by each regent or officer, was used to match the two anonymous versions of the same form. The priming manipulation consisted of using the context of a board meeting where the future of the college and the role of the college as “the conscience of dentistry” forms a general context. The follow-up survey contained language priming respondents to assume the role of a dentist in practice. Assume that you are completing this form as a dentist. If you are not currently in practice, try to imagine yourself about five years prior to retirement. In fact, it might be useful to recall a “typical” day in practice. How many patients did you see? Were there any that were especially challenging, technically or otherwise? Were there any staff or business issues? Did you have any contact with colleagues, either associates or others in your community? Did you do any business for “organized dentistry?”
The outcome variable was the difference in how the three questions about moral behavior were answered in the setting primed for general moral tone among one’s colleagues and the setting primed for typical individual practice. Each participant served as his or her own control. Only cases where regents and officers completed both surveys and where the identification numbers could be matched were used. There were 15 such pairs of responses. The consistency among the three items (the reliability of the test questions) had an acceptable Cronbach alpha of 0.782. This project was approved in the exempt category by the Institutional Review Board at the University of the Pacific, 16-74.
When the three moral items were rated in the context of the ACD board meeting, the average value was 3.633, where 5 = strongly agree (SD = 1.359). The same items rated in the context of private practice averaged closer to the neutral point, at 2.864 (SD = 1.495). The paired-comparison t-test value was 2.419 which is significant at p < .05. This is a statistically significant difference despite the small sample size. The effect size of the difference in contexts was an omega squared of 0.272. One quarter of the variation in how regents and officers responded to these moral challenges was explained by the context in which they answered the question.
This is first evidence that dentists respond to moral situations differently based on the moral identity they bring to the situation and that the moral identity activated can be primed by varying the context. Expecting more moral behavior may bring about more of it.
Years ago, ecological psychologist Roger Barker (1968) famously said, “I can better predict what a person is doing if I know where he [or she] is than if I know who he [or she] is.” Try it. If you knew that an individual is in a dental office, there are only a few options. If I said the same person was an extrovert, a Democrat, or a morally upright individual, it would be more than a long shot to guess what they are doing right now.
It might be disappointing to some that each of us has a small repertoire of moral lenses to use in various settings. This sounds too much like situational ethics – the idea that the most right thing for an individual to do could change depending on the circumstances. Although having a few bullet-proof rules is comforting, making them fit reality is seldom straightforward. The late eighteenth century philosopher Immanuel Kant (1788/2015) tried to argue that some rules never vary across circumstances, but few academic defend this position today. White lies or hiding Anne Frank from the Nazis would be out of bounds for a purist interpretation of veracity. Justice is argued many ways depending on whose standard is used (MacIntyre, 1988). Respect for persons quickly comes down to who that person is. The ADA code, for example, only mentions “respect for patients.” Most of us most of the time are strongly morally principled and, at the same time, quite adept at interpreting when circumstances call for another moral self-concept and another approach to others (Fletcher, 1966).
On the positive side, moral priming suggests a convenient and effective strategy for improving moral tone. If we adjust our moral character to match the expectations dominant in the setting, it should be simple enough to get better behavior by simply making it known that such behavior is expected. In our relations with others we can expect to get the kind of behavior we signal we are looking for. We tell each other constantly and are constantly being told what kind of moral character is appropriate for the situation.
Ethics education is assumed to involve a relatively permanent and comprehensive transformation of a person; moral priming is relatively transient and specific. We need to be cautious that the ethical language around the table in classrooms and council meeting (especially where one is away from the home environment) are likely not to travel well. There is an old question about if church were such a meaningful experience, why would people have to go every week? The answer, of course, is that the moral leaders in dentistry are not the only one’s engaged in priming.
Dentistry is a complex profession. For certain there are minimal standards for economic success and personal satisfaction. Professionalism and patient service are also important. There is a requirement for legal conformity and civic responsibility, and even much to be said for status among one’s colleagues. Which of these dimensions of practice speaks loudest? What moral character is expected to come forward? Dentists have a choice about who they want to be in each situation.
Here is the ACD Rule for Moral Identity: when there is conflict between professionalism and economic or other self-interests, professionalism takes precedence.
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Chambers, D. W. (2015). Moral communities and moral leadership. Journal of the American College of Dentists, 82 (4), 60-75.
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Dr. Chambers is a professor in the Department of Dental Practice at the University of the Pacific School of Dentistry and editor of the American College of Dentists. This paper is part of the ACD Gies Ethics Project.
[potential pull quotes]
Morality could be defined as the way we treat others who may or may not share our values so that we would feel comfortable exchanging places should circumstances call for that. The definition has these features: (a) there is no presumption that we have a special position based on our superior view of things, (b) we cannot be moral alone; and (c) moral opportunities are pervasive.
We need to develop and practice scripts for confronting those who are not upholding professional ideals and support systems for the many of us who would prefer not to do this alone.
An individual may possess very high levels of moral sensitivity or reflection, and so forth, yet go unnoticed as a positive force for professionalism in dentistry.
Certainly, it will be difficult to use moral identity traits that are not widely and conspicuously endorsed among our colleagues even if we have taken the right courses.
Perhaps we need not do an identity makeover on others. Perhaps it would be a worthy beginning to call out the best character that already exists in them.
Most of us most of the time are strongly morally principled and, at the same time, quite adept at interpreting when circumstances call for another moral self-concept and another approach to others.