Iranian Journal of Medical Ethics and History of Medicine

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 Introduction
Physicians often hesitate to disclose their errors due to fears of legal repercussions and stigma. Understanding their attitudes toward error prevention and professional behavior is essential. This study aimed to evaluate the attitudes of interns at Iran University of Medical Sciences regarding the disclosure of medical errors.

 Materials and Methods
This cross-sectional descriptive study included all interns who entered the university in 2017. Data were collected using the Persian version of the Medical Mistakes Survey questionnaire and analyzed with SPSS software version 26.

 Findings
Among the 186 participants, 66% reported committing a medical error. Only 21% fully disclosed errors with no significant adverse effects, while 31% disclosed errors with severe consequences.

 Conclusion
Most interns avoid fully disclosing errors, primarily due to fears of legal action and concerns about being underestimated by patients. Further studies are needed to enhance physicians' performance and patient safety.

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Decision making by a surrogate on behalf of incompetent patients is based on the ethical principle of "respect for autonomy". The increase in advanced health services has lead to more instances of decision making for incompetent patients receiving such services, and the treatment team usually asks a family member to serve for this purpose without being aware of the patient's preference. This study was conducted to assess patients' wishes and preferences regarding surrogate decision makers and determinants of such preferences.The study was cross-sectional, and samples were selected randomly from patients presenting at Farabi Eye Hospital clinics who were 18 years of age or older. Questionnaires were completed through interviews. Two hundred patients between 18 and 83 years old were interviewed. About 52% (n=105) were men, and 73% (n=77) were married. Among the married, the spouse was chosen as the surrogate decision maker in only 51% of cases. Among singles, boys preferred their father in 36% (n=9) of cases, while girls chose their father in 5.6% (n=1) of cases and the most frequent choice was other unmentioned people (33.3%, n=6). Most patients (93.5%) wished to be asked about their surrogate decision maker upon admission.Results of this study demonstrated that the people we usually consult for decisions concerning patient treatment are significantly different from patients' preferred surrogate decision makers. We suggest leaving the choice of surrogate decision maker to the patient while they are conscious.

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In this paper, different definitions of moral conflict and moral dilemma at two levels of recognition and observing moral duties are taken into consideration and some instances of usage of conflict in physiology (conflict of stimulant and goals) and sociology(conflict of roles and norms)are mentioned. Also concepts and constraints used in the moral dilemma, especially the concept of "ought to" and the concept of "Inescapable of wrongdoing" are surveyed in a logical analysis. If in definition of moral dilemma, the concept of “ought to” and “duties” being transformable to “commensurable reasons” and their justificatory values, many of apparent moral dilemmas will be solvable and only if the values contained in the duties, being incommensurable and non-infringement, moral wrongdoing will be inevitable. In this research, it will become clear that why and how proponents of the possibility of moral dilemmas under pressure of logical argument against the possibility of moral dilemmas and criticisms of opponents, in order to provide the necessary features for a genuine dilemma have suggested variety and supplementary definitions of moral dilemmas such as: natural, disjunctive, two shape and prohibition definitions. Natural definition of moral dilemma represents a situation in which the agent sees himself as both a moral duty, while he can't do it well. In disjunctive definition agent is required to perform either task. In two shape definition (consisting of the "ought to" and "ought not to"), on the one hand the agent ought to do and on the other hand ought not to do the same. In prohibition definition, the agent should not perform any of the two while he has no choice but to do one.

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Medical ethics is an interdisciplinary knowledge which increasingly developed during the last 30 years, and nowadays it becomes a part of medical student’s curriculum. Although, the quality of medical education has improved in Iran, but medical ethics teaching has not accomplished effective alteration yet. For deeper and more actual recognition of the challenges of medical ethics curriculum, we interviewed medical ethics instructors in a qualitative study. The data was collected by semi-structured interview with fourteen medical ethics instructors of Tehran University of Medical Sciences in 1389 and analyzed by Mairing content analyzing approach. Results of this study shows weaknesses and challenges in medical ethics curriculum which presented under five themes: comprehensiveness of goals, composing organization, proportion of content, active teaching method, and comprehensive system of evaluation. According to this the existing weaknesses and challenges of medical ethics curriculum can be considered as important obstacles in moral development of students. Considering those challenges, can develop medical ethics curriculum and introduce new models for medical ethics teaching.

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Documentation of accepted ethical behavior in special settings is one of the strategies employed to foster ethics in organizations. Such documents, known as codes of ethics, vary in different societies according to their cultural and ideological differences. Medical educators have dual professional roles (as physicians and teachers) that sometimes seem ethically incompatible. Therefore, having codes of ethics is essential in this profession. The aim of this study was to develop codes of ethics for clinical medicine educators with an Islamic-Iranian approach. This was a three stage developmental research. First, a comprehensive literature review was conducted. Using content analysis method, the first draft of a code of ethics for clinical medicine educators was prepared. Second, the draft was thoroughly and critically reviewed and revised in experts’ focus group discussion and the 2nd draft was devised. This was further reviewed by a group of 24 experts at the national level (validated) and revised according to their comments, and thus the 3rd draft was prepared to be presented for formal approval process. The final document includes 55 codes of ethics in 18 topics (conscientiousness, accountability, respectfulness, scientific excellence, respect for others’ freedom, equity, patience, religious commitment, modesty, trustworthiness, humility, contentment, relationship with coworkers, attentiveness toward patients, attentiveness toward learners, kindness, confidentiality, and discipline). It seems that extracting ethical concepts from the rich Islamic-Iranian cultural resources is feasible, and provides an appropriate basis for the development of ethical codes for medical educators. Compared to Western codes, such codes may be better accepted in Iranian contexts and will be implemented more readily if the organizational settings are prepared simultaneously.

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Truth telling is relaying the appropriate information to patients so that they can make informed decisions about their care and treatment. Truth encompasses all aspects of personal health. Due to inadequacy of research on the subject, the present study was conducted aiming to examine the phenomenology of truth telling based on nurses’ experiences. A phenomenological qualitative approach was used in the year 2011-12 in a teaching hospital in Tehran. A sample of nurses was chosen based on the purposeful sampling method. Sample size was dependent on the data saturation with a total of 14 participants at the end. Data gathering was done using deep interviews, and the data was later analyzed through Celasi method. Findings based on the nurses’ experiences of truth telling were extracted in 12 sub concepts and two main themes of reinforcing factors and obstacles to truth telling. According to these findings, nurses need to be informed of the patients’ conditions and be familiar with the appropriate methods and techniques for communication and transmission of bad news to patients in order to provide the best care, and this contributes to improvement of the performance of nurses.

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More than half a century has passed since the onset of successful life-saving and at times astonishing transplantations of organs from brain dead donors, numerous books and articles have been written on the subject, and local, regional and international meetings and conferences have been held. Nevertheless, no consensus has yet been reached among scholars of various fields such as medical sciences, religion, ethics and law on a number of generalities as well as theoretic and practical details of this issue. There have been discussions on topics such as the organ donor’s legal will, gaining consent while the donor is still alive, seeking consent from the brain dead patient’s family, nature of the required organ, observance of religious, cultural and conventional standards, individuals’ dignity and so on. The main challenge to overshadow other factors has so far been the discord among experts, physicians and religious scholars specifically, over determining the time the spirit leaves the body, and a unified definition of death. Some researchers have attempted to minimize religious, ethical and legal challenges and thus facilitate organ donation following brain death by emphasizing the urgency of organ donation and the practices related to certain specialties, and even maintain that brain death is the equivalent of death and a lifeless body. Others have focused on the time of death and the spirit leaving the body based on lexical, religious and medical evidence, regardless of equality of brain death and death, and ensuing rulings. These researchers have thus separated the solution to the problem of those in need of transplants from considering brain death to occur at the same time when the spirit leaves the body, and encourage experts to seek different solutions. Organ donation by brain dead patients is an undeniable social necessity that can be resolved without bringing about fundamental changes in lexical and jurisprudential concepts, and through other alternatives such as propounding “urgency”, declaring a patient “as good as dead” and in general “non-elucidated jurisprudential issues”. Through references to lexical, jurisprudential and medical sources and examination of previous research, the present article will review several definitions of death, spirit, and the time the spirit leaves the body, as these are concepts that are related to brain death for all practical purposes. The article also considers organ donation following brain death to be an undeniable and unavoidable fact of life in human societies, and will examine the necessity of altering lexical and jurisprudential concepts to accommodate current interests and goals.

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Organizational justice is of great importance particularly for hospital personnel, and job stress has the potential to put their health at risk. The purpose of this study was to determine the relationship between organizational justice and job stress among the personnel of a hospital in Isfahan. In this correlation study, the samples consisted of 150 personnel that were working in a governmental hospital in Isfahan. Samples were selected through convenience sampling in 2012. Data were gathered by personal data questionnaire, Niehoff organizational justice questionnaire and job stress questionnaire. Data were analyzed by descriptive and analytical statistics. Results showed that job stress among hospital personnel varied from 48.6% (moderate) to 39.4% (mild) and 12% (severe). Moreover, findings showed there was a relationship between organizational justice in the domain of interactional justice and job stress among hospital personnel (r = - 0.18, P = 0.03). According to the findings, it is essential to pay attention to the concept of organizational justice in hospitals in order to decrease job stress among the personnel.

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Justice is one of the main principles of ethics in the healthcare system, and its establishment at macro level depends on formulation of appropriate policies by policy-makers and healthcare providers. Health care policies and payment and reimbursement systems have a significant impact on health systems’ efficiency and cost control. In this paper, payment and reimbursement policies and their impact on financial incentives will be reviewed moreover, financial policies in the national health care in Iran and related challenges will be mentioned in brief. There is no doubt that none of the payment and reimbursement policies is perfect and each of them has the potential to put caregivers or health care providers financially at risk. Therefore, policy-makers should select a combination of the best approaches, considering socioeconomic factors, in order to provide a maximum coverage of health services and ensure fairness in the health system. Efficient payment and reimbursement approaches should undoubtedly preserve the rights of all parties in a fair and logical manner. Current national policy shows that a high percent of health care expenditures are financed through out-of-pocket payments, and therefore appropriate policies should be adopted to lighten this burden. Considering the accelerated trend toward the Family Doctor Plan in big cities in Iran, the present paper would be helpful for many health care providers, physicians and other health care professionals.

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Presumption of innocence is one of the fundamental principles of criminal law that has its roots in moral and religious principles. Presumption of innocence is consistent with human nature, and special attention has been paid to it in Islam. For this reason it has been included in our constitutional law as well as in the constitutions and ordinary laws of other nations, and this indicates its significance. In Shiite jurisprudence there are two major theories on the responsibility of physicians as “daman al-tabib”. Most jurists (famous) consider the physician responsible even if he or she has committed no fault. Only a minority of jurists (less-known) consider the physician to have no responsibility. Islamic criminal law believes the physician to have absolute liability, although medical practices have become more sensitive than in the past and medical incidents have increased as a result of new technology and new methods of treatment. The present study intends to adopt a new approach to rules and principles of jurisprudence, and study the necessity of using them according to the requirements of time in solving everyday problems. Moreover, the study seeks ways to prevent the regression of those rules. Therefore, it seems essential that the golden principle of presumption of innocence be applied to physicians as the manifestation of God's healing, and more attention be paid to it.

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Ethical decision making is an important issue in medical professional ethics. Recent advances in medical sciences and development of new ethical issues in medical ethics have added to the importance and specific complexities of this issue. In fact, ethical decision making is a manifestation of moral values in practical work. In this study, the ethical decision making process in medical ethics has been reviewed in Amir al-Mu'minin Ali (A.S.)’s views in Nahj al-Balagha. Therefore, the issue of ethical decision making in various scientific articles and resources were studied and examples of ethical decision making, its components and its determinants in Nahj al-Balagha were analyzed. In Ali (A.S.)’s word, the ethical decision-making components include knowledge and insight, trust, counseling, adherence to moral values, objectivity, commitment to justice, responsibility, privacy, confidentiality, obedience to law, monotheistic belief and human dignity. In Nahj al-Balagha, the barriers to ethical decision making include: the inability to predict and evaluate the probable consequences, hastiness, being overcome by feelings and financial incentives. In conclusion, according to Ali (A.S.)’s views, physicians’ decisions can be ethical when they perceive their profession not as a means of financial gain, but rather as a moral responsibility, and consider both human and divine rights in their professional practice.

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In this article, we aim to discuss one of the essential concepts of medicine. As a rule, such studies attempt to clarify the philosophical principals of medicine, whereby the act of medic can be regulated based on his clear perceptions of the principles of his knowledge. In this article, we will evaluate the concept of causation in medicine from a philosophical point of view and through historical review, and we aim to clarify the significance of such concepts in clinical decisions. Medicine is an academic discipline dedicated to learning about illnesses and their causes, curing ailments and promoting social as well as individual health. There are four general paradigms in the world of medicine, and accordingly four definitions of causation. Along the line of these thaughts are the views of modern philosophers such as rationalists, empiricists and post-modern philosophers. In this article we will look at these four medical paradigms and consequently the four definitions of causation. Hippocratic paradigm, with reprsentatives such as Hippocrates, Ibn Sina and Galen, was the first paradigm in medicine to presuppose a rationalistic and realisitc view about causation.Biomedical paradigm aquires an attitude similar to logical positivism, seeing causation as a real concept that is true and is provable not through intelect, but by experience. Within this paradigm, a critical clinical approach is specially noticable according to which causation is not a real and necessary concept, but a mental, unprovable concept that is abtained through symmetry-based association, repetition and statistics. Finally, in the post-modern hermenutical paradigm, discussions of scientific causation and biological and mechanistic topics are replaced by ethical discussions about humans thus the causation is marginalized and loses its relevance.

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In recent years, the financial relationship between the physician and the patient and some issues such as informal payments for health care have arisen as an unethical but common problem in many countries, including the Islamic Republic of Iran. Such issues are a threat to the professional reputation of physicians, and can have their own causes in different parts of the world. This study attempts to assess the causes of informal payments and the manners in which they are done in the hospitals of the Kerman Province in Iran in 2012. This study was carried out using qualitative research methods, and semi-structured interviews. Structured interviews were conducted on a purposeful sample of 45 participants including patients, providers and policy makers in the Kerman province in Iran in 2012. This study was authorized by the ethics committee of Kerman University of Medical Sciences, and the consent form was completed by all participants. In this study the participants were asked questions regarding reasons for informal payments, and data were analyzed using content analysis. There are several reasons for making informal payments, which include cultural, legal and quality factors. A number of reasons for asking informal payments by providers were discovered, including those related to tariffs, structural factors and ethical factors as well as to demonstrate the skill and competence of service providers. Most of the reasons discovered for informal payments in Iran are similar to other countries in the world. They showed that inadequate funding of the health systems and inadequate formal payments to providers are the most important supply-side factors leading to informal payments. Given that qualitative studies usually cover potential reasons only, further studies are needed to investigate the matter more extensively.