Iranian Journal of Medical Ethics and History of Medicine

---

Healthy volunteers are the first group who take part in experimental studies on the efficacy of new drugs. Parallel with expanding the boundaries of medical science, medical research has shown rapid growth which has caused new and critical ethical challenges in medical research.A clinical trial is one of the essential methods in clinical research and a very challenging method from the ethical viewpoint.Recruiting healthy volunteer participants is necessary in clinical trials of drugs, and it requires special and careful ethical considerations. Although recruiting healthy volunteers is not limited to clinical trials, we have focused our discussion on ethical issues of research on healthy volunteers in this kind of study. In this paper, ethical challenges of involving healthy volunteers in clinical trials have been discussed in four domains of risk-benefit assessment, fair subject recruitment, incentives, and informed consent. The authors believe and argue that using the daily life risks standard as the acceptable risk for healthy volunteers is impractical. We suggest defining a reasonable risk that is acceptable to the research ethics committee. The ethical committee, as a jury, can then evaluate the public acceptance of the risks.

---

In many countries around the world, we find important evidence about violation of ethics in medical research. In the United States, the history of unethical or even inhuman experiments on human subjects dates back to the time of slavery, and unfortunately, most subjects of these experiments were poor or black people, slaves, prisoners and physical/mentally ill patients. For instance, we refer to the Tuskegee study that was done on black people. Other examples are tormenting experiments on American or Nazi prisoners. In this paper, we will review some infamous unethical experiments and researches in terms of neglecting human dignity and the validity of the research. On the other hand, in response to these dreadful events, some ethical codes and guidelines have been established which we shall review. For instance, the Belmont Report and the Nuremberg Code which were developed in response to the Tuskegee study and Nazi experiments on human subjects, respectively. The medical history of our country, Iran, is free of such troubling acts however, this does not mean that ethical standards in medical research are fully observed. Therefore, in addition to items that have been enacted so far, to prevent such faults, it is necessary to enact professional codes and guidelines or legislated laws and regulations too.

---

The astonishing advances in medical sciences, owing to research in recent decades, have brought about endless advantages for humans, including improved level of health, prevention of communicable disease, and curative treatments. This trend, despite its great benefits, may undermine the principle of respect for human vulnerability and personal integrity, and expose certain risks to target populations or those excluded from investigations. Therefore, the principle of respect for human vulnerability and personal integrity has received attention by policy makers, law makers, human rights activists, and international organizations. It is necessary to cite the important question that arises here is there any contradiction between international documents' demands such as the Universal Declaration on the Human Genome and Human Rights and the legal actions of some countries on the principle and merits of Islamic teaching? If not, what type of activity should be undertaken by legislators in Islamic countries in general, and the Iranian Parliament in particular? An in-depth discussion of the issue reveals the fact that there is no contradiction between Islamic law and the principle of respect for human vulnerability and personal integrity. Therefore, there is room for the national legislative body to take legal actions in order to achieve the objectives of the principle of respect for human vulnerability and personal integrity in medical research and practice as articulated by international instruments such as the Universal Declaration on Bioethics and Human Rights in particular.

---

Research ethics, as one of the main issues of modern bioethics, has attracted the interest of scientists and ethicists in various areas of science and technology around the world. Research Ethics Committees (RECs) have been established to improve putting ethics into practice in the field of research. RECs, fortunately, have received a great deal of attention in different countries, and their mission, goals, and tasks have been described in many national and international guidelines. Ethical guidelines for biomedical research and RECs administrative regulations have been developed in Iran too. The need for special training courses for capacitating members has been emphasized in both international guides and our national administrative regulations for RECs. In this brief article, we present suggestions concerning course presentation and contents, which are provided by international assemblies. In view of the fact that many RECs in our country do not have specific plans for their members' primary training and continuing education, there seems to be a need for fundamental changes in the educational prerequisites for membership in this important organization.

---

In spite of increasing advances in technology, medical equipments, costs, geriatric population, consideration to ethical and legal issues has increased in nursing profession. This study aimed to explore ethical codes and consideration of ethical issues and severity of ethical distress experienced by nurses at intensive care units. A cross-sectional survey using questionnaire was conducted by a census of nurses in intensive care units in educational and treatment centers of Hamadan. Nurses value most the ethical codes related to responsibility (95.1%), accountability (95.1%), patient support (77.3%), secret keeping (83.4%), and honesty (78.5%). They studied patient rights statement 2.47 times with standard deviation of 2.86. Only 50.3 percent of nurses had education about professional ethics. Nurses had mean of mark in severity of ethical distress 99.34 ±46.61. Severity of ethical distress was moderate in nurses. There was not significant relationship between demographic data and severity of ethical distress. There are more needs to assess for effects and effective factors on ethical distress in intensive care units nurses.

---

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.

---

---

In recent years, a new manner has been common practice in emergency departments (EDs) of governmental hospitals in Iran, in which, of course illegally, patients are encouraged to self-discharge or refer to other EDs. This is done by giving incomplete or even false information and deceiving patients. The purpose of this study is to identify the underlying causes from the point of view of EDs' personnel to clarify the root of this burden for authorities and pave the way for more studies. This is a cross-sectional descriptive-analytic study, gathering opinions via questionnaire and/or direct interview with open-ended questions. During November and December 2009, hospital managers, hospital heads, faculty members, residents in specialties involved with the ED, interns, ED nurses, and nurse supervisors were interviewed regarding the frequency of such instances in their hospital, the main violators, and its possible causes and determinants.In this study 114 persons from different groups took part. From participants' point of view, the main violators in EDs are junior residents and interns 48 (42.1%) participants pointed to junior residents and 29 (25.4%) participants found interns responsible. The estimated number of patients which were refused during a week was stated as 18.1 ± 15.6 (range between 0 to 90). Among participants remarks, the most important factors which lead staff to non-admission were high work load, overcrowding of EDs, lack of facilities, lack of any motivation or incentive for doing tough tasks, inappropriate patient transfer by city emergency system, bad policies and rules, lack of sufficient supervision from deputies, and improper work sharing between different levels.Patient non-admission and diversion through deception is a common practice among EDs of educational hospitals in Tehran. High work load and overcrowding of these centers should be considered a high priority target for interventions. Further studies are highly suggested to find appropriate solutions. In future studies, junior residents and interns should be considered as main target groups.

---

Spiritual care includes assistance in performing religious rituals to support those seeking connection to the spiritual world. It forms an essential part of holistic care and helps finding answers to issues concerning life, pain, and death. This study was conducted to understand cancer patients' perception of spiritual care.A qualitative content analysis approach was applied to conduct the study. Semi-structured interviews were undertaken with convenience sampling of 17 cancer patients and their family members in oncology wards of a hospital in Tehran and Behnam Daheshpor Charity Organization. The recorded interviews were transcribed verbatim. For data reduction, data were labeled and coded before content analysis.The following themes were identified: characteristics and duties of nurses with a spiritual approach in religious and non religious domains, care with a spiritual approach in religious and non religious domains (emotional, communicational, functional), barriers to spiritual care.According to our findings, nurses do not satisfy all spiritual needs of the participants, because the characteristics and practices of nurses do not meet the expectations of patients and their family members, and ward environment does not support such care.

---

Posthumous reproduction has recently emerged in line with the development of assisted reproduction technology (ART) methods. In this method, individuals take steps to freeze their gametes or embryos for posthumous insemination or reproduction. However, diverse moral and legal questions ensue, and it is important to preserve human dignity and protect the child's rights and interests. In this regard, from an ethical point of view, we discuss supporting and opposing arguments on autonomy, consent, and the child’s interests. We reason that any measure to be taken on the gamete after death has to be based on the autonomy of the deceased and his/her explicit or implicit consent as to the posthumous use of the gamete. On the legal aspects, we discuss proprietary rights over gametes, filiation of the child, and his/her inheritance. In our opinion, non-financial authority over one’s organs, tissues and cells, as well as parenthood and conditional inheritance are plausible answers in these regards. Evidently, the legal system cannot address these issues without taking into account the ART developments and contemporary expediencies. This in turn depends on taking a modern stance relying on justifiable moral and legal principles. Moreover, it will help identify shortcomings of the legal system in this regard.

---

Valuing human being is the foundation of nursing and the essence of care. Specified aspects of the health care are not compatible with the humanistic agenda. Thus, the challenge is to integrate a humanistic approach into nursing. Nursing scientists have tried to solve this problem by developing human centered theories. Internal evaluation of these theories helps decide about their applicability in solving this problem and enhancing a humanistic approach.The aim of this article is to investigate the applicability of some humanistic theories to nurses' practice. The method is critical review of related literature. Data have been gathered by consulting books, searching some data bases, and using some guiding questions. Findings revealed that humanistic nursing theories, transpersonal care, and human development are becoming specifically expanded under the influence of humanism philosophy. In these theories, human being is free and prepared to grow in a mutual interaction with the environment. Nursing flows from its presence along side others and respect for people's potentials, and has a share in human growth. Emphasis on human interactions has increased the scope of applicability for these theories, but some characteristics of these theories, users, and different context necessitate modifying these theories and developing new ones.      

---

For some infertile couples, egg donation is the only option. In egg sharing programs, patients share half of their eggs with another couple in exchange for a discount on assisted reproductive technology. In many countries, using this method is legally discussed. Iran is the only Islamic country in which donation programs are practiced, so, we designed this study to compare egg sharing to ordinary egg donation from ethical, legal, and religious aspects.A complete review of ethical issues and debates about egg donation and sharing was done. For religious issues, we consulted clergies, Islamic texts, and current decrees (fatwas). Social issues and legal problems were examined by consulting expert opinion and jurists. Also a complete review of literature was done. Egg donation and egg sharing are both religiously accepted in Iran by the Shiite clergies as they are considered completely similar. Egg sharing has some religious (seeing and touching the female genitalia) and social (preventing repetitive donation) advantages to egg donation as well as avoiding complications of fertility drugs and procedures, financial and trading issues, advertisement and brokers. However, there are some disadvantages with egg sharing, such as reduced likelihood of conception by donating half of the eggs, challenges related to donor health, and emotional stress of failure for the donor and success for the recipient, which can be prevented by careful case selection, psychology and genetics consultation, and  practicing anonymity. As a result, egg sharing is ethically and religiously more acceptable than commercial egg donation.   

---

Recent advances in cloning have offered hopes for disease treatment and resolving some other difficulties related to health, but this technology comes with social, legal, ethical, religious and other questions, and has caused different reactions worldwide. While some countries have enacted legislations on cloning, other countries have no clear law. Many countries and organizations, for various reasons including ethical concerns, have taken strong stand against reproductive cloning, and some even against research cloning. Some refer to the positive results of cloning and are in favor. Overall, most are in favor of cell and tissue cloning for therapeutic reasons and against reproductive cloning. In general, cloning is an important development in genetics and biotechnology that can be both lifesaving and destructive. Therefore, decision makers should be aware of its positive aspects for human health and prevent potential social and ethical problems through appropriate legislation In this paper, we present the opinions of opposers and supporters, and an overview of the position of countries and organizations regarding human cloning.

---

Al-Akawayni is considered one of the greatest and most reputable Iranian physicians of the fourth century AH whose medical works and expertise have been reliable and acceptable sources in most periods of the history of medicine. Unfortunately, old books do not reveal much about his life and works, and what we know about him is based on his own statements and evidence and inferences we have made from his famous work "Hidayat al-Mutaallimin fi-al-Tibb" (Learner's guide to medicine). He was a student of Abu Al Qasem Moqaneiy, who, in turn, was a student of Muhammad Zakaria Razi. His works, especially "Hidayat al-Mutaallimin fi-al-Tibb", are considered reliable medical texts along with other great medical textbooks of Iran. This book is important from several viewpoints. First, it is the oldest available medical text in Persian second, it is rich in linguistic and literary technicalities third, it is valuable from a medical and scientific point of view, especially traditional medicine fourth, it is an important source to learn the names of a large number of medications, herbal medicines, and scholars in the history of Iranian medicine. 

---

Nurses play an important role in end-of-life care for dying patients. Based on the essence of the work environment, nurses are confronted with dying patients and their requests for euthanasia more than other care givers. However, little is known about their attitudes towards euthanasia. Hence, aim of present study was to determine nurses' attitudes toward euthanasia. In this descriptive-analytical study, 91 nurses who employed in intensive care units situated in educational and medical hospitals affiliated to Guilan University of Medical Sciences participated. Nurses attitudes evaluated by using Euthanasia Attitude Scale. Data analyzed by descriptive and inferential statistics (T-test, ANOVA and generalized linear models) by SPSS software version 16. Majority of nurses (83.5%) had negative attitude toward euthanasia. Univariate analysis showed no significant statistical relationship between demographic factors and nurses' attitude toward euthanasia, whilst age (P < 0.029) and employment status (P < 0.004) were related to nurses' attitude toward euthanasia in regression analysis.     
Findings of the present study showed that majority of nurse's believe in care of dying patients for health maintenance and life continuance even in the end stage of life. They don't accept euthanasia at any condition. Perhaps, more accurate studies need to assess other confounding factors such as nurses' knowledge, practice and role.

---

Disclosing the diagnosis of cancer to a patient could impact various aspects of their life. The present study was performed to evaluate the views of cancer patients about disclosure of the diagnosis of disease to them. The present study was conducted on 385 cancer patients in three teaching hospitals (Afzalipour, Shafa, and Bahonar) affiliated to Kerman University of Medical Sciences between 2010 and 2011. These patients were evaluated for their views on revealing the diagnosis to them using a questionnaire that included the type of cancer, demographic information and their preferred manner of being informed of the diagnosis. Out of 385 cancer patients, 155 patients (%40) were aware of the diagnosis of their disease. The majority of patients who were aware of their diagnosis (%89) said they would like to know the diagnosis before treatment. Almost all patients who knew the diagnosis preferred to be aware of the prognosis of the disease and the complications of treatment. The only significant demographic variable was sex men were more eager to know the diagnosis of the disease (P value< 0.05). This study showed that the majority of cancer patients would like to be aware of the diagnosis, even though most of them were unaware that they had cancer.

---

Errors occur commonly in hospitals and nurses are potential observers of these misconducts and they can prevent them by reporting. This research studies the types of errors, misconducts, and inappropriate situations in the nursing field, compares these errors in private and public hospitals and finally studies individuals' reactions to these errors (whistle-blowing and not whistle-blowing). Two hundred and forty five subjects were chosen out of 2260 nurses in Isfahan hospitals. In this study, a list of errors, misconducts and whistle-blowing criteria by McDonald instrument was used. Results showed that there is significant difference between error models in private and public hospitals, also between strategies used by whistle-blowers and non whistle-blowers when they observed errors, misconduct and inappropriate situations.  Sixty-two percent of nurses revealed errors after observing them. Identifying the types of errors can help health decision makers to decrease them and will raise awareness of this issue. In addition, by decreasing the impediments of whistle-blowing, errors and organizational misconducts will be decreased.

---

Medicine is known as a combination of science and art. Besides knowledge, a good physician should be equipped with the art of establishing communication with patients. The keystone of any efficient relationship like a therapeutic one is trust, and its deterioration makes the relationship deficient and based on mere need. Therefore, establishing an efficient relationship brings about positive results in treatment. In the last two decades, the trend in the physician-patient relationship has greatly changed, so that patient-centered care is now in focus. In this kind of relationship, physicians recognize patients as respectable human beings with their unique beliefs, attitudes, and concerns, etc. In this paper we intend to provide a brief introduction to the concept of physician-patient relationship and its chronological changes. Also, common models of physician-patient relationships (e.g. paternalistic, etc) are introduced, compared, and their most obvious strengths and weak points are analyzed. At the end, a succinct analysis on the dominant model(s) of physician-patient relationship in Iran&aposs medical settings has been provided, and the necessity of compiling a model based on Islamic values is proposed.

---

Trust is a key element in the physician-patient relationship. Imam Jafar Sadiq (A.S.) stated that the proficient and trusted physician is in equal level of a just jurisprudent. Ancient ethical texts put much emphasis on physicians to be trusted. Nowadays, trust is a component of social health we believe that in the physician-patient relationship, trust has a significant impact on the practice, and increases the effectiveness of treatment and the satisfaction of patient and physician? also patient autonomy is preserved, health is positively reinforced, and patients will be more serious and less negligent with expenses, treatment, and follow up. This paper is a review/analytical article, and aims at classifying trust and examining its role in communication between physician and patient. If limited to practice, trust in the physician - patient relationship is divided into two types:

1- Unconditional trust, which means full confidence with no autonomy

2- Conditional trust, which entails maintaining autonomy.

 In the first type, where patient's autonomy is foregone, both patient and physician can be blamed. The patient is to blame due to an absence of self confidence and lack of participation in decision making and treatment, and the physician might in his place have the tendency to patronize. In this article we emphasize the importance of trust and warn against paternalism and conclude that if doctors truly comprehend the meaning of trust, they will try to avoid paternalism.

---

Rapid development in assisted reproductive techniques has brought hope to many childless couples, while it has created new social, ethical and legal dilemmas. Stored frozen gametes and embryos have led to situations where the surviving spouse wants to create offspring after the person's death. Also, the possibility of sperm retrieval even after 36 hours of death, and getting oocytes from aborted fetus or brain dead people has brought a new term: "posthumous assisted reproduction". Posthumous assisted reproduction is the most challenging, difficult, and sensitive issue to be discussed ethically and religiously. In this paper, the acceptability of the posthumous reproduction in Islamic context was evaluated. In Islamic societies where infertility is viewed as a problem of families, posthumous assisted reproduction seems unacceptable. Major concerns such as consent and ownership of the gametes after death, family, marriage and welfare of the child are discussed together with some legal issues. Based on infertility as a disease of family, posthumous assisted reproduction is unacceptable even with previously frozen gametes or embryos. Also, Islamic vision to marriage, consent and welfare of the child confirms the unacceptability. There must be law or guideline to ban this procedure in Islamic contexts.