Skip to main content
  • Research article
  • Open access
  • Published:

Just say “no”: Can dentists refuse care on the basis of finances? A survey using an ethical vignette in an Iranian Dental School



Decision making when patients ask a dentist for fee reduction is a real ethical dilemma at dental settings. The aim of this study was to evaluate how dental students and tutors think about their position for, or against fee reduction at dental offices.


It was a questionnaire-based survey, which examined the ethical attitudes of students and tutors of an Iranian Dental School. The questionnaire included a vignette about an ethical dilemma at a dental office. Different ethical approaches, i.e. duty-based, virtue-oriented and consequentialist arguments, for or against fee reduction at dental office were suggested. Respondents were asked to rank those ethical options. Data was entered and analyzed in SPSS 16.0.


121 dental students and thirty-six faculty members (dental specialists) participated in this study. It revealed that a majority of dental students and tutors (68%) are in favor of charging patients less, when facing an imagined request at dental office, using either virtue-oriented (54%) or consequentialist (14%) argument for fee reduction. The difference between rankings of four options was statistically significant, while no statistically significant difference exists neither between male and female respondents, nor students and tutors.


This case study provides a basis for fruitful discussions in ethics courses for dental students. Our study suggests that financial issues should be considered as a part of ethical training within the dental student's curriculum.

Peer Review reports


For both patients who need dental care, and for the dentists who treat them, financial issues are among the main questions that arise for both parties. Several surveys have shown that the high cost of treatment, and the financial limitations faced by many patients are the main barriers to accessing dental care [1,2,3]. These barriers inevitably have negative effects on oral health outcomes [4, 5]. Policies that promote opportunities for patients with lower social-economic status to see a dentist may reduce the single most important impediment to regular dental care [6].

Furthermore, the financial discussions that must take place, affect the dentist-patient relationship, and are a routine challenge at dental settings. Offices that have an efficient, thoughtful, and context specific process for talking to their patients about the cost of treatment and the method of payment have higher financial profits, for having a straightforward initial discussion relieves uncertainty for both dentists and patients [7, 8]. Many of the treatment plans are rejected simply because the patient cannot afford to pay either at the time, or even over a period of weeks [9]. Because each dentist must confront the choice to offer fee reduction or refuse care where the request is made, we argue that it is a significant ethical and practical challenge as each decides, for example, how to react to the request from disadvantaged patients for reduction in their treatment fees. This situation is more likely to happen in oral health systems where out-of-pocket payment is dominant, but also is encountered when eligibility for exemptions or reduced prices, known as disease-specific responses, are adjudicated. Financial inaccessibility and inability to pay are typical system constraints [10].

“On average, do graduates benefitting from state tuition subsidies charge their patients less?” [11] This is one of the questions Bartolami raised in his reflection on dental graduates’ sense of gratitude for the public’s generosity. While charging patients less could be seen as a moral obligation of dentists, especially those who benefitted from public funds, or who have a practice with a significant economic advantages and generally well-paying patients, this obligation might be understood in other, but equally ethical ways.

Dentists tend to state that they choose their profession based on a desire to behave altruistically [12], which seems to be supported by prosocial attitude of dental students [11]. Focusing on professional issues, such as social and economic situations, which are related to patients’ non-medical problems, could be an effective way for discussing ethical issues of dental practice and promoting ethical sensitivity of dental students within the teaching of professional conduct. In this study, we studied how dental students and tutors thought about their position for, or against fee reduction at dental offices and the way they put forward their arguments to justify their position.


This study was a questionnaire-based survey, which examined the ethical attitudes of students and tutors of Mashhad Dental School, in Mashhad, Iran. The questionnaire was distributed in the Medical Ethics course to two sequential groups of six-year dental students in July and December 2017. Additionally, it was sent via email to the tutors of the School of Dentistry, Mashhad University of Medical Sciences, in Mashhad, Iran. Those who did not respond in a week received a reminder. While all the students at the classes completed the questionnaire, the response rate of the tutors to our online survey was 40.0%. The study was approved by the Institutional Review Board of Mashhad Dental School.

The questionnaire included a vignette about an ethical dilemma at a dental office (Additional file 1). The vignette describes a meeting of five dentists. The host, Dr. E. raises an issue regarding his difficulty in decision making when patients ask him or her for fee reduction. Dr. E. wants to know how his or her colleagues behave in such circumstances, and how they think about this problem.

Four approaches are then taken by the colleagues of Dr. E. They include:

  1. A

    Consequentialist argument against fee reduction—Dr. A. believes if a dentist began to accept requests for fee reduction, it would gradually raise other patient’s expectations, which may result in unfavorable consequences.

  2. B

    Virtue-oriented argument for fee reduction—Dr. B. considers maintaining the virtuous character of the dentist as the most important response to the dilemma. A good dentist could not remain indifferent about the unaffordable tariffs for treatments for his or her patient, and could never deny care.

  3. C

    Duty-based argument against fee reduction—According to Dr. C. making fee reduction is never listed as a dentist's duty. We have to be careful to adhere to our obligations, not necessarily more. We are not charity.

  4. D

    Consequentialist argument for fee reduction—Dr. D. believes rejecting patients' request to make a reduction would damage our reputation and would be harmful for our profession in long-term.

Respondents were asked to rate these four approaches according to their own opinion and intuition in such a way that the first rank is the most favorable option for them.

Data was entered and analyzed in SPSS 16.0. Statistical analysis of the ordinal data was done using non-parametric tests including Friedman and Mann–Whitney U tests.


The questionnaire was filled out by 157 respondents, including 121 sixth-year dental students and thirty-six tutors of Mashhad Dental School. Ninety-four respondents (59.9%) were female.

The second option, which accounted for the virtue-oriented argument for fee reduction, was chosen as the first best option by 54 percent of respondents. The option D, accounted for the consequentialist argument against fee reduction, was selected as the least favored option by 47 percent of respondents. Figure 1 shows the descriptive report of proportion of rankings for each option.

Fig. 1
figure 1

Descriptive ranking of the suggested approaches

The difference between rankings of four options was statistically significant (p value < 0.001). The most favorable option, i.e. virtue-oriented argument for fee reduction, had the mean rank of 1.85. It followed sequentially by duty-based argument against, consequentialist argument for, and consequentialist argument against fee reduction. Table 1 displays the mean rank of four options.

Table 1 Mean ranks of the options of the vignette

No statistically significant difference exists neither between male and female respondents (p value = 0.60), nor students and tutors (p value = 0.22).


This study examined the ethical response and moral justification of dental students and faculty members when confronted with controversial issue in dentistry—fee reduction. It revealed that the majority of dental students and tutors in the second biggest city of Iran believe that accepting patients’ request for a fee reduction is the ethically preferable behavior. Almost 68 percent of participants selected either a virtue-oriented (54%) or a consequentialist (14%) argument for fee reduction as their best option.

Virtues define how we behave when no one else is watching, and generally are described as the qualities or excellences of character to which humans ought to aspire. As described by Aristotle, and extrapolated by medieval philosophers [13], it refers to a trait or character that is deemed to be morally good and thus is valued as a foundation of a principled life. Virtue considerations include reflection on how each act shapes the moral agent. In our survey a virtue ethics approach was the most favored one among the options offered. The consequentialist approach judges an action based on its consequences. This approach scored lowest among the options. Seventy-two percent of respondents regarded the consequentialist arguments, either for or against fee reduction, as the least justifiable response. There was no significant difference, neither between male and female respondents, nor between faculty members and students. We suggest that this may be a sign that there is convergent ethical intuition of the participants.

Similar arguments about other ethical and professional dilemmas arise in previous studies. For example, the same consequentialist approach at option D seems to be taken by Ayn, et al., who puts emphasis on improving communication skills in dentistry education [7], or by Gosden, et al., stating that clinical behavior of patients is affected by the method of payment [14]. The other consequentialist argument, put forward in the option A, is also in line with some suggested cost control strategies [15].

Yet the majority of our students and tutors acted in accordance with virtue, rejecting consequentialist arguments. The virtue-oriented approach has also been the mainstream attitude of many medical ethicists and is taken by many who discussed ethical aspects of dental practice [8, 16, 17]. However, it could be reasonably argued that there is a constant interplay between virtue, moral duty and consequentialist doctrine during fee reduction. Further investigation could be pursued to establish criteria for determining which patients will receive free or reduced-fee care. It would help individual dentists contribute in helping to overcome barriers in access to dental care.

The main limitation of our study was related to using the plain short vignette, which for the sake of encouraging compliance, did not involve the complex factors interplaying in the real clinical settings. There are a bunch of different patient- and dentist-factors that could affect the communication between patient and dentist during fee reduction. Issues such as the alternative treatment planning by dentists, bargaining attitude of patients, and the extent of the fee reduction could be incorporated in developing the vignettes in next studies. Considering such complexities would be helpful for simulating real life scenarios and making participants careful ethical deliberation.

Another limitation of our study was the potential difference in training about ethical schools of thought for different populations of students. There was also no comparison between senior and junior students.

Creating imaginative ways of thinking about common, yet important dilemmas, such as fee reduction is important. More study will need to be done to explore whether reducing the fee for dental work will reduce the value of the work among patients; whether asking for a fee reduction will become a habit; whether dentists will begin to expect this from their patients, and how any these questions, by focusing on the materialistic view of the profession of dentistry diminishes its nobility as a calling.


We argue that using this case study provides a basis for useful discussions in ethics courses for dental students. It is also suggested that such financial issues be considered as a part of the professionalization and ethical training within the dental student's curriculum.

Availability of data and materials

The dataset supporting the results of this article are available from the corresponding author on reasonable request.



Institutional Review Board


  1. Aguirre-Zero O, Westerhold C, Goldsworthy R, et al. Identification of barriers and beliefs influencing engagement by adult and teen Mexican-Americans in oral health behaviors. Community Dent Health. 2016;33(1):44–7.

    Google Scholar 

  2. Thompson B, Cooney P, Lawrence H, et al. The potential oral health impact of cost barriers to dental care: findings from a Canadian population-based study. BMC Oral Health. 2014;25(14):78.

    Article  Google Scholar 

  3. kenwilo D, . A difference-in-differences analysis of the effect of free dental check-ups in Scotland. Soc Sci Med. 2013;83:10–8.

    Article  Google Scholar 

  4. Yuen HK, Shotwell MS, Magruder KM, et al. Factors associated with oral problems among adults with spinal cord injury. J Spinal Cord Med. 2009;32:408–15.

    Article  Google Scholar 

  5. Locker D, Maggirias J, Quiñonez C. Income, dental insurance coverage and financial barriers to dental care among Canadian adults. J Public Health Dent. 2011;71(4):327–34.

    Article  Google Scholar 

  6. Grembowski D, Andersen RM, Chen M-S. A public health model of the dental care process. Med Care Rev. 1989;46:439–96.

    Article  Google Scholar 

  7. Ayn C, Robinson L, Nason A, et al. Determining recommendations for improvement of communication skills training in dental education: a scoping review. J Dent Educ. 2017;81(4):479–88.

    Article  Google Scholar 

  8. Nash DA. Ethics in dentistry: review and critique of Principles of Ethics and Code of Professional Conduct. J Am Dent Assoc. 1984;109(4):597–603.

    Article  Google Scholar 

  9. Larijani B, Aramesh K. Fee splitting among general practitioners: a cross-sectional study in Iran. Arch Iran Med. 2016;19(12):861–5.

    Google Scholar 

  10. Travis P, Bennett S, Haines A, et al. Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet. 2004;364(9437):900–6.

    Article  Google Scholar 

  11. Bertolami CN, Berne R. Access to care: leveraging dental education. J Dent Educ. 2014;78(12):1481–8.

    Article  Google Scholar 

  12. Galizzi MM, Tammi T, Godager G, et al. Provider altruism in health economics. Washington: National Institute for Health and Welfare; 2015.

    Google Scholar 

  13. DuBois JM, Kraus EM, Mikulec AA, Cruz-Flores S, Bakanas E. A humble task: restoring virtue in an age of conflicted interests. Acad Med. 2013;88(7):924–8.

    Article  Google Scholar 

  14. Gosden T, Forland F, Kristiansen IS, et al. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database Syst Rev. 2000;3:CD002215.

    Google Scholar 

  15. Barer ML, Evans RG, Labelle RJ. Fee controls as cost control: tales from the frozen North. Milbank Q. 1988;66(1):1–64.

    Article  Google Scholar 

  16. Nayak PP, Raju VK, Nanjundaiah V, et al. Ethical conventions: a study on dental practitioner’s knowledge and practice of ethics in their line of work in Bangalore, India. J Clin Diagn Res. 2016;10(8):ZC84-7.

    Google Scholar 

  17. Broida JH, Lerner M. Knowledge of patient’s method of payment by physicians in a group practice. Public Health Rep. 1975;90(2):113–8.

    Google Scholar 

Download references


This paper considerably benefitted from comments made by Professor Laurie Zoloth.


There has been no significant financial support for this work that could have influenced its outcome.

Author information

Authors and Affiliations



A.K.: Designed and performed experiments, supervised the research and co-wrote the paper. M.F. and S.Sh.: Performed analyses, co-wrote the paper. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Ali Kazemian.

Ethics declarations

Ethics approval and consent to participate

The study was considered to be exempt from review by the IRB of Mashhad Dental School, since the research was conducted in established educational setting. It complies with national guidelines. The letter of exempt from IRB review is submitted separately. According to national regulations and the IRB of Mashhad Dental School, the participation of students in the study that was conducted in established educational setting was regarded as consent to participate. The participants had an option to opt-out providing they did not consent to participate in the study.

Consent for publication

We declare that the manuscript has been read and approved by all authors, that the requirements for authorship have been met, and that we believe that the manuscript represents honest work.

Competing interests

The authors declare that there is no conflict of interest regarding the publication of this article.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Additional file 1

. The vignette used as the questionnaire of the study.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kazemian, A., Fayyazi, M. & Shafiee, S. Just say “no”: Can dentists refuse care on the basis of finances? A survey using an ethical vignette in an Iranian Dental School. BMC Med Ethics 21, 109 (2020).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: