Iranian Journal of Medical Ethics and History of Medicine

Bioethical principles and medical futility

Saeedeh Saeedi Tehrani1

Medical futility refers to diagnostic, treatment, and rehabilitation interventions that are unlikely to produce any positive outcome for patients. Doctors should beware of such actions due to their professional commitments. There are ambiguities in the definition of futility that have been the subject of many studies. In this paper, relevant literature was reviewed to find a definition for futility from the perspective of the four bioethical principles.Determining the futility of an action, whether it is the request of the patient, their family or service providers, is a highly sensitive matter that can lead to unethical decisions in the medical profession.Autonomy is a concept that is related to the diverse views on treatment objectives. In this paper we investigated the issues of physician and patient autonomy, and the differences between the values of the people involved. We have also discussed the concept of palliative care with an attempt to clarify the difference between this type of care and futile care, and to determine the boundaries. Another focus of our study was situations where physicians and other health care providers deliver futile treatment for various purposes. Such cases involve factors that may influence the judgment of physicians, and some of them are unethical due to incentives such as financial gain.Finally, ethical decision-making in this area is only possible through clarification of the different aspects of the issue and prioritization by experts and professionals. In order to do so, all circumstances need to be taken into account, including allocation of scarce resources within the health care system and fairness. Moreover, medical staff should have access to the necessary information so that they can make ethical decisions in different situations.

The ethical reasoning ability of nurses and nursing students: a literature review

Mohammad Zirak

The principal objective of the nursing profession is to provide evidence-based and competent care mainly based on humanitarian and ethical principles. Ethical care is contingent on a proper level of moral reasoning, which can be categorized into pre-conventional, conventional and post-conventional reasoning. At the pre-conventional level, individuals are mostly self-oriented and prefer obedience to avoid blame. At the conventional level people apply laws and social principles to decision-making, and at the post-conventional level they try to guide their actions and behaviors with regard to ethical principles and make humanist and ethical decisions. This study aimed to assess the level of moral reasoning in nurses and nursing students by providing an analysis of the existing literature on moral reasoning.For the purpose of this study, we conducted an extensive search of the papers published between 1980 and 2014 on international electronic databases including Scopus, Google scholar, Science Direct, PubMed, Proqust and Elsevier. We also reviewed papers published between 1985 and the autumn of 2014 on Persian electronic databases Sid, Magiran and Iran Medex. A broad range of search keywords were used such as: ethical growth, moral growth, ethical development, moral development, ethical reasoning, moral reasoning, nurse, and nursing student. In total, 35 studies were reviewed at this stage.Based on the results of the above-mentioned studies, most nursing students and nurses reason at the conventional and post-conventional level, and nursing students reason at a higher ethical level in comparison with nurses. We also found that teaching ethical concepts helps improve ethical reasoning, and that an inverse relationship exists between clinical experiences and ethical reasoning.Although in most studies, the level of moral reasoning in nursing students and nurses was found to be at the conventional and post-conventional level, this is not enough to provide superior professional care. It is therefore essential to apply the necessary measures such as improving clinical environments and the ethical education system to further promote the reasoning ability of nurses and nursing students, so that they can make their decisions based on ethical principles and at the post-conventional level

Modeling the ethical behavior of nurses using the theory of virtue ethics

Zahra Nikkhah Farkhani

The purpose of this research was to explore the components of nurses’ ethical conduct in public hospitals in Mashhad. This study employed an eclectic method for research and followed a mixed exploratory design. A qualitative study was first performed, and then based on the results the quantitative method was applied. The statistical population consisted of all the nurses in public hospitals in the city of Mashhad. In order to collect data, in-depth semi-structured interviews were conducted, and the data were then analyzed using thematic content analysis. A preliminary model was developed for the nurses' ethical conduct comprising three levels. The first level covered areas of ethical behavior toward patients, patients’ families and the core group. At the second level 13 dimensions and at the third, 51 components (themes) were abstracted. The questionnaire was then distributed among 176 experienced nurses employed in public hospitals in Mashhad. In order to assess the fit of the model in quantitative research, data were analyzed using confirmatory factor analysis and AMOS software. The results of the confirmatory factor analysis showed that all dimensions and components were acceptable with the exception of the component "patient education". Using AMOS software, the comparative fit index (CFI) was calculated at 0.9, which indicates a good fit of the model and validates the components and sub-components. The results of this study can guide human resource managers in public hospitals to promote ethical conduct in nurses.

Human dignity: Criterion

Ahmad Fayaz-Bakhsh

The criteria for human dignity are among the most important topics associated with the concept. Some related questions are what makes man worthy of dignity, and what properties make him more dignified than other creatures? Although biological classifications of species should be considered in humanities, research on dignity must focus on differences that are fundamental and separate humans from all other species. Morphological, genetic and communal differences cannot be the criteria for dignity, and behaviors are subject to individual outlooks. This manner of reasoning guided scholars to categorize humans on the basis of wisdom, but the author of the present article believes that wisdom cannot be the criterion for dignity. There is a degree of intelligence and wisdom in other creatures that is not sufficient to make a fundamental differentiating factor. Like other faculties, wisdom may be regarded as an instrument for a better life. The authors believes that the “authority” to choose (that is, free will) is the essential difference between humans and other creatures because the latter are driven only by their structures or needs. This authority enables people to choose between good and bad or desirable and undesirable, and shapes most human values. Consequently, this authority creates the basis for dignity and any given type of choice passes its value on to the chooser.

A comparison of the moral intelligence of nurses in civilian and military hospitals

Yaser Saeid

Nowadays, ethics is an important factor that can determine the clinical competency of nurses. The aim of this study was to compare the moral intelligence of nurses in civilian and military hospitals.In this descriptive-comparative study, 315 nurses from hospitals in Tehran and Kerman were recruited by convenience sampling. Lennick & Kiel’s Moral Competency Inventory was used for data collection. The data were analyzed by SPSS software version 17 using descriptive and inferential statistical tests including T- test, ANOVA and Chi-square test.149 study subjects were military nurses and the remaining 166 were civilians. The nurses’ moral intelligence was found to be at an average level. On the other hand, there was a statistically significant difference between the moral intelligence level of civilian and military nurses (P < 0.001).The results showed that the moral intelligence of most nurses in this study was at an average level. It is therefore recommended that health managers pay more attention to this issue and incorporate it into the required courses for their employees especially during service training. Moreover, offering extensive training courses on ethical issues is a solution that should be considered in military hospitals.

Protective nursing advocacy: an evaluation of the beliefs and actions of nurses in educational hospitals affiliated to Birjand University of Medical Sciences during 2014

Seyyed Abolfazl Vagharseyyedin

Patient advocacy is an inherent element of professional nursing ethics that helps to protect the patient’s rights. Many codes of ethics in nursing are concerned with this particular role of nurses. The present study aimed to evaluate the protective advocacy beliefs and actions of the nurses employed in educational hospitals affiliated to Birjand University of Medical Sciences during 2014. Data in this cross-sectional study were collected using a demographic characteristics questionnaire and the protective nursing advocacy scale. Participants included 248 nurses working in six hospitals located in Southern Khorasan province selected by randomized stratified sampling. The Cronbach’s alpha for Protective Nursing Advocacy Scale was 0.74. Data were analyzed in SPSS version 16 using descriptive and inferential statistical tests.Moderate levels of protective advocacy were observed in the majority of participants (80.6%), with a total mean score of 137.39  13.65. Some of the protective advocacy components had significant correlations with age, work experience, type of ward, employment status, and history of participation in ethics education programs (P < 0.05). In other words, the total mean score of advocacy and some of its components were significantly higher among nurses who had attended ethics education programs than those who had not (P < 0.05). Moreover, nurses who were older had more work experience, had worked in the emergency ward, and had a permanent employment status had higher scores of advocacy than others. The total mean score of advocacy among the nurses in this study was relatively appropriate, although strategies are needed to improve the score. It can also be assumed that nurses’ involvement in ethics education programs can increase the level of nursing advocacy. On the other hand, changing nurses’ temporary employment status to permanent status and providing job security for them may reinforce protective advocacy beliefs and actions in nurses.

Professional values from nursing students’ perspective in Kerman province: a descriptive study

Azam Pourama

Values in the nursing profession improve the quality of patient care and enhance job satisfaction among nurses. Therefore, promoting professional nursing values is an important aspect of nursing education. The purpose of the present study was to evaluate the professional values among nursing students in their last semester in nursing schools across Kerman province.A total of 152 students in their last semester in five schools of nursing across Kerman province (cities of Kerman, Bam, Jiroft, Zarand and Rafsanjan) participated in this cross-sectional study. Data were collected using a two-part questionnaire that included demographic variables and Nursing Professional Values Scale - Revised (NPVS-R) in five dimensions (caring, activism, trust, professionalism and justice). The reliability of the questionnaire using Cronbach's alpha coefficient was calculated at 0.91. Data were analyzed using descriptive statistics (mean and standard deviation) and inferential non-parametric statistical tests (Mann-Whitney and Spearman’s rho correlation coefficient) in SPSS 18.Of the five dimensions of professional values, the highest mean score (37.8 ± 4.6) pertained to the caring dimension and the lowest mean score (12.68 ± 1.92) was related to the justice dimension. There was a significant negative correlation between age and professional values (r = - 0.02, P = 0.01). Results of the Mann-Whitney test showed a statistically significant difference between the mean scores of the justice, activism, trust and professionalism dimensions and sex (P < 0.05) and between the total mean score of professional values and the place of education (P = 0.003).From the perspective of students, the dimensions of professional values were prioritized in the following order: caring, trust, activism, professionalism and justice. Nevertheless, the majority of students were not aware of the importance of some dimensions of professional values. Therefore, appropriate planning and teaching methods and strategies are required to enhance all dimensions of professional values.

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