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 education7, 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. 16-18 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.