Iranian Journal of Medical Ethics and History of Medicine

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Throughout history, various religions and schools of philosophy have viewed human dignity as an important issue and a topic of discussion. The theoretical roots of this concept lies in ancient philosophies and religions, in Medieval as well as Modern periods, the most significant of which may be the Cyrus Cylinder, Stoicism, teachings of philosophers of the Renaissance period and of thinkers such as Immanuel Kant and John Locke, the Universal Declaration of Human Rights, and Abrahamic religions. Human dignity is infallibly referred to as being intrinsic and inviolable, and although there is no one comprehensive, inclusive and universally accepted definition for the term, it is fundamentally the characteristic that lies at the core of the basic rights of humans. In biomedical ethics there are two different dimensions to human dignity: the dignity of the individual and the dignity of humanity as such, and while the former is considered to be absolute, the latter is relative, as it is realized simply by belonging to the human race. Human dignity applies to all the principles of biomedical ethics, and sets the standards for all manners of reasoning and inference in this field. In areas such as research ethics, ethics of beginning of life and end of life care, and public health ethics, human dignity has clear requirements and implications, for instance regarding issues such as unethical uses of the embryo, fetus, and the human body for commercial purposes, the right to live and die with dignity near the end of life, and the right to basic indiscriminate health care.

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Observing patients’ rights in health care services plays an important role in improving and adjusting the doctor-patient relationship and is therefore of great significance in health systems management. Considering the role it plays as an important philosophical part of modern ethics in ethical and social functions, empathy has received much attention in various areas of research such as psychology, behavioral studies, neurosciences and psychiatry. The present study will first offer an overview of the history of empathy and its positive effects on the interactions between doctors and patients, and then move on to propose strategies to promote empathy in doctor-patient relationships. Empathy plays a significant role in patient empowerment and satisfaction, and therefore studying its effects on teaching medical ethics as a factor that can positively influence the doctor-patient relationship can provide all, including organizations such as the Ministry of Health and psychology and counseling centers, with valuable guidelines to promote mental health, from prevention to treatment.

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Illnesses and their treatment, pharmacy and pharmacology, medical equipment, hygiene and health related topics, health economics, preventative measures, lab equipment and supplies, human resource service delivery models, education and training of health care professional, and associated areas of law are collectively referred to as the health care system. At times it is even difficult to separate health care from social injuries and civil conditions, since these can pose direct or indirect threats to individuals’ health. As health policy makers, managers and professionals demand and encourage the observance of ethical considerations in providing health care, neglect of the legal aspect of the health care system can bring about unethical phenomena that necessitate legal measures. The present paper aimed to determine whether the general traditional legal classifications, that is, jurisdiction and sovereignty, apply to the health care system, and if so, which of the two it falls under. What further highlights the significance of answers to such questions is the fact that they are closely connected to regulations of the health care system. It could well be that some companies in the health industry have a negative effect on the ethical conduct of physicians and other health care professionals, as due to their commercial nature and structure, these companies are dominated by rules of business, and this exerts limitations on their observance of ethical considerations. This study investigated a number of such seemingly legitimate situations and the problems associated with them, hoping to eliminate legal conflicts and promote ethics in the process of providing health care in the society.

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During the Qajar era, most cities, including Esfahan, suffered poor hygiene conditions due to an overall lack of hygiene facilities. Esfahan was a big city that faced a shortage of hospitals, pharmacies and physicians, and this meant that large numbers of people would die as a result of outbreaks of communicable diseases. The new government, therefore, began a series of actions with the purpose of promoting hygiene in the city, including establishment of new hospitals, systematizing pharmacies and physicians, mass vaccinations, improvements in the hygiene condition of public places such as bathhouses, eateries, inns and slaughterhouses. For the most part, such measures resulted in a growth of population during those years. The present paper aimed to shed light on the hygiene conditions prevalent in the city of Esfahan during the first Pahlavi period by using historic documents, newspapers and other sources available. It employed a library research method along with comparison and analysis of existing sources, original ones in particular. To this end, the required data was initially collected and then organized and analyzed, and this historical research was ultimately structured based on the inferred results.

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Based on the definition offered by ancient scholars and philosophers, the term “ethics” refers to a certain set of qualities and character traits, and an ethical person is one who possesses those qualities. This definition is still accepted, although it does not undertake the actions of an ethical person, and does not clarify the stance regarding an ethical person who happens to commit an unethical act. While supporting the definition above, this paper will investigate people’s behaviors individually through an analytical approach, logical arguments, and by applying falsification criticism. It will then proceed to define the term “piety” and provide a comprehensive exposition of an ethical person. The above-mentioned exposition is offered in this paper for the first time and presents a fresh approach to defining morality. It combines the terms piety and ethics to argue that an ethical person is a pious individual who not only possesses ethical characteristics, but also is sensitive to each one of his/her behaviors.

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Nurses have to cope with various forms of tension in the workplace on a daily basis. One of the factors affecting the moral distress experienced by nurses is the ethical climate prevalent in clinical environments. The present study aimed to establish the relationship between moral distress and nurses’ ethical work environment. This was a cross-sectional, correlational study on 210 nurses in select departments of medical/educational centers of the Tehran University of Medical Sciences in 2009. Data collection tools included a demographic questionnaire, Corley’s Moral Distress Scale, and Olson's Ethical Climate Questionnaire. Data analysis was performed using SPSS version 14. Findings confirmed that the nurses under study were tolerating an average amount of moral distress, although they did not perceive the frequency of morally stressful situations to be particularly high. There was no significant relationship between the moral distress of the nurses under study and their evaluation of the ethical climate of their workplace. Of the five factors affecting the ethical climate, there was a meaningful indirect relationship between managers and frequency of moral distress (P ≤ 0.04), and patients and frequency and intensity of moral distress (P = 0.001). The results obtained through this research indicated a need for authorities to pay more attention to medical/educational centers and devise various strategies in order to make work environments more ethical, so that nurses can continue to offer health care services in more relaxed environments and with less stress.

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Nurses are confronted with numerous situations calling for moral decision-making in their workplace every day. Nursing students should therefore attain a satisfactory level of moral development during their university years. The present study was conducted to determine nursing students’ level of moral development, as there seems to be a shortage of similar studies throughout the country. This descriptive, correlational research was performed in 2010 study samples were 115 junior and senior students of the Department of Nursing and Midwifery of Tabriz University of Medical University who were selected by census. These students’ level of moral development was evaluated through the Nursing Dilemma Test (NDT), which has been created based on Kohlberg’s theory of ethical development. NDT assesses nurses’ moral development in three levels: pre-conventional, conventional and post-conventional, and evaluates their observance of clinical considerations at the same time. A number of the participants’ sociodemographic characteristics were also collected through a questionnaire. Data analysis was performed using SPSS statistical software, and descriptive and inferential statistics. According to the findings of this study, 13 students (11.3%) were in the pre-conventional, 33 (28.7%) in the conventional, and 55 (47.8%) in the post-conventional level, and 14 (12.1%) took clinical considerations into account more than others. There seemed to be no meaningful statistical relationship between the students’ moral development and their age (P = 0.49), sex (P = 0.21), marital status (P = 0.79), place of education (P = 0.32), and year of education (P = 0.92). These results showed that although approximately half of the students under study were in the post-conventional level, which is an acceptable level of moral development, a great percentage were still in the lower levels. This means that those in administrative positions in nursing departments need to pay more attention to the moral education of nursing students.

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A review of the history of the Patient’s Bill of Rights reveals the universal significance of this subject in health systems management. There is a long history of attempts to raise respect for patient’s rights and setting the legal frameworks associated with those rights in the health care of many countries. The present study aimed to evaluate observance of the Patient’s Bill of Rights according to patients in the teaching hospitals of the Mazandaran University of Medical Sciences. This descriptive cross-sectional study was carried out in 2009 in all 4 teaching hospitals of the Mazandaran University of Medical Sciences on 200 patients who were either hospitalized or about to be discharged at the time. Data were collected through interviews, using a fifteen-item Likert type questionnaire based on the Patient’s Bill of Rights, and its validity and reliability had been confirmed. Data analysis was performed through ANOVAs and t-tests, using SPSS version 17 software. The results showed that according to the population under study, the patients’ rights were respected in 14.59% of the cases based on the overall score of the Patient’s Bill of Rights. This figure was 16.63% for respect for patients, their privacy and, patient non-discrimination, 14.17% for patient information availability right, 14.15% for the right to make choices and decisions freely, and 13.20% regarding complaints. There was no meaningful relationship between patients’ views on observance of their rights and their sex (P = 0.106), education level (P = 0.723), marital status (P =0.260) and place of residence (P = 0.101). Based on the findings of this study, observance of the Patient’s Bill of Rights was not satisfactory according to the population under study and from their viewpoint. It is therefore recommended that measures be taken to eliminate any obstacles preventing observance of patients’ rights and to improve the present conditions of hospitals in this respect.

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Duty-based or deontological ethics is among much discussed, major schools of thought in philosophy of medical ethics that can provide additional solutions to various ethical challenges in modern medicine. Duty-based ethics generally refers to a set of principles according to which the criteria for determining whether an action is right or wrong is the action itself and its properties, regardless of its benefits or consequences in other words, proponents of duty-based ethics believe that performing ethical acts in spite of their consequences is an obligation which lies in the acts themselves rather than the ends they bring, as is the belief of the proponents of results-oriented ethics. Advocates of results-oriented ethics are concerned with the consequences of their actions, and advocates of duty-based ethics with their duties. The present paper offers an overview of the latter and its two main subdivisions: act- and rule deontological theories, in order to evaluate and analyze duty-based ethics. In ethical philosophy, duty-based theories have received less criticism in general compared to results-oriented theories, as they are more difficult to criticize.

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In the past generations and throughout the history of dentistry, horrific and deadly epidemics of the diseases transmitted through blood have not been a concern for those in the dental care profession. This has been due to the success of this profession in maintaining the oral health of patients. Questions such as whether dental treatments can potentially spread HIV and AIDS have therefore not been discussed extensively, and there seems to be a shortage of reference for dentists to find comprehensive and accurate answers to these questions. As a matter of fact, several generations of dentists, and health care providers in general, have continued to perform their duties despite the possibility that they could be exposing their patients to a deadly infection, and have not even apprehended a fatal pandemic. Consequently, it is not surprising that the professional norms that today’s dentists were educated on during their training years should fail to give clear answers to their questions regarding AIDS and HIV nowadays. The present paper will cover this issue in connection to HIV positive patients from the ethical and professional point of view.

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With the development of professionalism in modern-day nursing, concepts such as accountability and civil responsibility have found a special place in nursing, since responsibility is an intrinsic part of this profession. Accountability typically brings civil responsibility, which means an individual can be held legally responsible for injury they have caused to another person. Due to the autonomy that nurses enjoy in their practice, they have legal responsibilities, which in turn expose them to complaints and lawsuits on grounds of negligence more often than in the past. The objective of this paper was to familiarize nurses with the concept of civil responsibility, and to help them prevent the damages arising from it, as well as to ensure patients’ safety and rights. This was an analytical study that examined the concept of nurses’ civil responsibility based on books and articles on the subject. The study will first explicate the general definition of civil responsibility, and then proceed to explain its application to the nursing profession, and the more common stages of litigation, prosecution and defense. The nursing profession today can benefit from a modern outlook on civil responsibility and nursing errors in order to improve teaching methods in providing better patient care and reduce errors. This can eventually enhance the quality of care, and lead to a decrease in nurses’ civil responsibilities and prevention of a waste of public resources.

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New antiviral remedies have greatly improved the prognosis of patients infected with AIDS, as well as their life expectancy and quality of life, and assisted reproductive techniques have made it possible for many HIV positive patients to have healthy children. Nevertheless, most assisted reproduction centers continue to reject these couples, and this is a factor that contributes to their isolation from the society. The present study was performed through document and library research, and the results were investigated from the viewpoints of the infected couple, their future children, and health care staff. Social and legal issues were evaluated through consultation and collaboration of experts, and related articles, guidelines and accessible material were examined for this purpose. Every individual has the right to reproduction. If it is possible for HIV positive couples to have children with the help of fertility lab techniques, and provided that throughout the process there is no danger of disease transmission to others and particularly the embryo, ART centers should not reject HIV positive couples. Rejection of these couples is against the principles of medical ethics and in violation of the current effective laws of the country. On the other hand, acceptance of patients infected with Hepatitis type C, advanced cancers, mental diseases, and so on is further proof that rejecting HIV positive couples is a form of discrimination and unethical. The word HIV itself is synonymous with the stigma of social deviance, and it seems children of infected parents are not in the ideal position from the public point of view. One step that needs to be taken is for the society to try to remove this stigma and provide support for all chronically ill patients. There is no valid justification for rejecting HIV positive couples in ART centers, and it appears to be unethical and a violation of human rights to deny these couples the right to have healthy children through modern technology.

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Human cloning is one of the latest and most complicated developments in the field of medical and genetic sciences that could fulfill man’s dream of eternal life. Scientists’ achievements in this respect, however, have brought about many concerns for thinkers, particularly ethics scholars. Human and animal cloning have been examined from different angles, but one basic aspect of human cloning has received less attention from researchers and scientists, and that is the autonomy of the cloned person the reason is that gaining informed consent, which is one of the most important principles of medical ethics in human experiments, is impossible in the case of human clones. Free will lies at the core of human perfection and divine revelation, and one important issue that the present study concerns itself with is whether or not technologies such as cloning or embryonic genetic modification violate the autonomy of cloned persons. This paper attempted to look into such issues regarding human cloning through library research.

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Giasaddin Mansour Dashtaki Shirazi was a prominent scholar and philosopher in the post-Islamic Iran. Among the fields he was proficient and knowledgeable in, the least attention has been paid to him as an influential figure in medicine, and this has in turn led to his expertise in other sciences to be neglected as well. Among Dashtaki’s works two are on medicine, and there are also historic accounts of his hygiene behavior and adherence to medical recommendations. These are indicative of Dashtaki being an outstanding figure in medicine in spite of his involvement in other scientific and administrative endeavors. The present paper will employ a descriptive-analytical approach to investigate his influence on medicine and his medical treatise Ma’alem-o-Shafa. Based on the findings of this study, any research on the Iranian or Islamic medicine of the 10th century H.Q. would be incomplete without studying Dashtaki and Ma’alem-o-Shafa. It is therefore recommended that Ma’alem-o-Shafa be translated and published so that it can be used in research of this type.

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Divine religions have adopted various stances regarding cloning, and the Jewish faith has likewise examined the issue and investigated both its classifications. The present paper is a case study of the viewpoints of Jewish scholars on both reproductive and therapeutic cloning. The results showed that regarding therapeutic cloning, Jewish scholars believe in three different viewpoints: impermissiblity, permissibility and necessity, while they only believe in the first two regarding reproductive cloning, and they present reasoning for their views. This was a library research based on books and articles in Farsi and other languages as well as online sources.

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Medical Ethics is a branch of science that has received attention due to developments in medical treatments and technology as well as complex social transformations and involvement of social sciences, law and so on in medicine. The present paper attempted to perform an analysis and historiography of scientific publications in the field of medical ethics and their growth and development rate between the years 1990 and 2008. This study used scientometrics to examine scientific publications in the field of medical ethics between 1990 and 2008 in three bibliographic databases: The Arts & Humanities Citation Index (A&HCI), the Social Sciences Citation Index (SSCI), and the Science Citation Index Expanded (SCIE). An evaluation of the nature of the documents showed that 5690 bibliographic items had been presented in fifteen different formats. The documents had all been published in 1289 journals by 3634 universities or higher education institutions, with the Harvard University in the lead. 10326 authors had composed articles during this period and made reference to a total of 109301 sources. The Journal of Medical Ethics had published the majority of works in the field. One major topic in this field is “medical ethics education and its necessity”, as medical policies and regulations are constantly changing in order to ensure patients’ rights. Consequently, a need is clearly felt for teaching medical ethics in order to offer medical care in an ethical and human manner, and to make difficult decisions concerning new technologies.

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Making decisions for recipients of health care while offering clinical care is an important part of nurses’ responsibilities. In order to ensure patient satisfaction, nurses are obligated to observe ethical standards in the decision-making process. This paper aimed to determine the effect of teaching professional ethical principles on ethical sensitivity in nurses’ decision-making. In this semi-empirical study, 80 Social Security nurses were selected through purposive sampling and were then randomly placed in two groups of 40 each, the intervention group and the control group. Research tool was the Ethical Sensitivity Scale Questionnaire for decision-making, the validity of which was assessed using content validity, and whose reliability was confirmed with a Cronbach’s alpha coefficient of 0.83 for internal consistency. At first the ethical sensitivity in decision-making was evaluated in both groups, and then an educational workshop on nursing ethics was held for the intervention group every other week the workshop consisted of 4 three-hour sessions, and upon completion of this workshop, both groups filled in the questionnaire once more, and data were analyzed using SPSS software. There was no significant difference between the average ethical sensitivity in decision-making of the two groups before the intervention after the intervention, however, the difference was meaningful (P = 0.001). Moreover, the average ethical sensitivity in decision-making of the intervention group was significantly different after the intervention (P = 0.001). Based on the findings of this study, teaching nursing ethical principles has a positive effect on nurses’ ethical sensitivity in decision-making. It is therefore recommended that this educational program be offered to nursing students and health care staff.

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Attempts to promote medical ethics principles on the national level should be consistent with the needs, expectations of the target audience, social orientations and determination of priorities. The present study was conducted through distribution of a questionnaire containing twenty medical ethics topics, and thus the priorities of instructors, researchers and policy makers regarding medical ethics were determined on a national level. Through determination of medical ethics priorities in the country, the study aimed to encourage a scientific approach to the issues and challenges faced throughout the nation based on the opinions of thinkers of this field, and to help resolve each of those issues according to national priorities. The findings revealed ten priorities in the field of medical ethics nationwide: patients’ rights, doctor-patient relationship, justice in the distribution of health care resources, autonomy and informed consent, the financial relationship between doctor and patient, hospital ethics committees, ethical considerations in public health, strengthening and capacity building in teaching medical ethics, ethical considerations in medical education, and medical research ethics.

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One of the manifestations of patient autonomy in practice is gaining informed consent prior to any invasive procedure. In Iran, the process of obtaining informed consent to surgical procedures is currently limited to the patient signing a consent form that often does not offer specific information on the procedure, and patients are not given adequate time to read the form. In order to improve the present circumstances, authors of this study created information sheets specific to each class of surgical procedure, and performed an evaluation of the effectiveness of these sheets in increasing patient awareness and satisfaction. Handouts containing specialized information on various surgical procedures were distributed among 110 patients hospitalized to undergo elective surgeries in surgical wards 1, 3, 4 and 5 of Imam Khomeini Hospital Complex and surgical ward 3 of Sina Hospital the patients received the handouts prior to procedures, and were free to use the information as they wished. These patients were then interviewed through an oral questionnaire after the procedure and at the closest time possible to their discharge. At a different time, 110 other patients in similar conditions and locality were interviewed after surgical operations and as close to being discharged as possible, but without receiving information sheets. The above-mentioned questionnaire contained essay type questions regarding patients’ information about their medical conditions and the required surgical procedures, and patients were also asked about their level of satisfaction with the information they had received. The mean score for patients’ overall knowledge in the intervention group was 48.8%, and the same score was 44.6% in the control group. Distribution of specific information on the surgical procedures among the patients in the intervention group did not have a significant effect on their overall knowledge (p = 0.140), and only raised their awareness of the side effects associated with the procedures (p  0.001). Similarly, patient satisfaction levels were 60.2% in the intervention group and 56.4% in the control group, and distribution of information sheets did not affect the overall satisfaction level of patients significantly (p = 0.166), and it only increased their satisfaction with the information they had received regarding their convalescence period after surgery (p = 0.033). Since distribution of specialized information sheets like the ones used in this study generally appears to be inadequate in increasing patient awareness and satisfaction, it is recommended that in the process of obtaining informed consent, physicians dedicate enough time to educate patients on their conditions and their different aspects rather than simply present them with a consent form.

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Adherence to ethical standards in the medical profession is one of the fundamental principles of the traditional Iranian medicine, and its significance is reflected in the words and works of founders of this school of medicine. One particularly valuable source is the esteemed work by the Iranian scholar Hakim Seyed Mohammad Hussein Aghili Khorasani Shirazi entitled “Kholasat-Al-Hekmat”, which was written more than two centuries ago. The present paper is a descriptive library research on this work. One significant characteristic of this book is the author’s careful attention to details in clarifying the principles of medical ethics. Although the “four principles” approach to medical ethics is a relatively recent concept in modern medicine, it has been fastidiously expounded and evaluated in Iranian works on medicine. For young physicians and researchers, being familiar with such sources and their analysis and comparison based on principles of modern medical ethics is a clear indication of the humoral medicine being deep-rooted and ethics based. The present study aimed to investigate and analyze medical ethics as presented in Kholasat-Al-Hekmat.