Iranian Journal of Medical Ethics and History of Medicine

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Considering the importance of medicine and the ever-increasing developments in medical research, the implementation of such research according to the ethical principles and criteria of creditable national and international declarations is of great significance. According to these declarations, the researcher has the highest responsibility to observe the rights and safety of participants. The present study intends to survey the rate of observance of research ethics in proposals approved at Urmia University of Medical Sciences between the years 2003 and 2008. Three hundred and twenty four research proposals that had been approved between 2003 and 2008 were evaluated retrospectively. Related checklists (self- constructed ones and World Health Organization checklists) were completed for each project, a statistical analysis of the results was done by SPSS software, and descriptive statistics were subsequently extracted.  A summary of the most important results is as follows: In 85.5% of the proposals, the ethical considerations part was completed. In 68.4% of the cases the participants were aware of participating in the study and in 67.9% of the cases the informed consent of participants was obtained, 50.9% of which was in written form. Among clinical trials, in 80% of the proposals informed consent was obtained, 85% of which was written. Out of 60 clinical trials, 37 projects (62%) were confirmed by the ethics committee. Considering the results obtained in this study, principles of research ethics were applied more closely in this study compared to similar studies in Iran. It seems this is due to the establishment and launch of regional ethics committees in 2003 and afterwards. However, in order to bring these measures closer to current standards, holding educational workshops for honorable members of scientific boards and students is recommended. Moreover, more accurate supervision of ethics committees, especially in clinical trials and animal experimentations, seems to be beneficial.

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The study of work ethics has gained great significance in recent years following the failures of major corporations and the West’s crisis. The main objective of this study is to examine the relationship between Islamic work ethics (IWE) and organizational commitment and its three dimensions including affective, continuance and normative commitments. This is a descriptive study that has been conducted in 2010. One hundred and fifty nine employees participated in this study who selected from hygiene, nursing & midwifery, pharmacy & medicinal sciences, dentistry, rehabilitation sciences, and management & information faculties through stratified random sampling. Data were collected via the 17-item Islamic Work Ethics Questionnaire, constructed by Ali (2000), and the 24-item Organizational Commitment and its dimensions questionnaire, constructed by Meyer & Allen (1991). The collected data were analyzed through correlation and regression using SPSS17. The result of factor analysis confirmed the multidimensional nature of organizational commitment. The result of correlation and regression analysis also showed that there is a positive and direct relationship between IWE and total organizational commitment and its three dimensions. The demographical variables did not impact on IWE and organizational commitment. According to the results, the employees of Isfahan University of Medical Sciences are committed to the organization either because of an emotional bond to the organization or in the absence of better job opportunities outside the organization. It may be beneficial to convey these results to managers in order to make them aware of the fact that the employees are not reluctant to leave the organization for a better job with better conditions. In view of the relationship between Islamic work ethics and organizational commitment, it is recommended that university directors and presidents attempt to increase organizational commitment by providing ethical codes and promoting Islamic work ethics principles.

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Nurses and administrators can identify and implement mechanisms to manage, change, and improve the ethical climate in their workplace through an understanding and awareness of this concept as well as how it is perceived by everyone involved.This study aimed to compare the nurses’ perception of the actual and ideal organizational ethical climate in hospitals of Ahwaz Juondishapour University of Medical Sciences. This was a cross-sectional descriptive study conducted on 558 nurses working at 9 medical centers of Ahwaz Jondishapour University of Medical Sciences selected by systematic sampling. Data instrument consisted of 2 parts: 1) demographic characteristics, and 2) actual & ideal climate questionnaire based on the Farsi version of Olson’s ethical climate questionnaire, used to assess nurses’ perception of the hospital ethical climate in 5 categories (managers, colleagues, physicians, patients, and hospitals). Descriptive and inferential statistical tests, independent T-test and One-Way ANOVA were used to analyze the data.Results demonstrated a positive hospital ethical climate (mean = 3.66), while the nurses’ perception of the ideal ethical climate was positive as well. A significant difference was found between the mean scores of the nurses’ perceptions of actual & ideal ethical climates (P<0.05). Results demonstrated a significant relationship between nurses’ work experience & organizational level, and their perceptions of the hospital ethical climate.A positive ethical climate exists in hospitals, although it is far from the ideal ethical climate, and therefore managers must maintain the actual ethical climate and at the same time implement strategies to improve their hospitals’ ethical climate.

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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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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.

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In order to achieve teamwork-based and integrated care, one of the issues in health care is the implementation of ethics and values in teamwork. The aim of this study is to develop the interprofessional collaborative ethics framework.This cross sectional study was conducted in two phases. In phase one, core competencies of the interprofessional collaborative ethics were determined by literature review. In phase two, Delphi rounds of experts were undertaken to validate the competencies and calculate content validity indexes through Content Validity Ratio (CVR) and Content Validity Index (CVI).The interviews and Delphi rounds identified 12 competencies categorized in three core themes including patient-centered values, interprofessional collaborative ethics, and team-based values. In phase two, based on the mean scores of importance, utility, and clarity, patient center value (4.9), interprofessional ethics competencies (4.6), and team-based values (4.5) were determined as essential themes.In conclusion, the validation of the inter-professional ethics framework was found to be acceptable in the Iranian context. Therefore, the framework for teaching and evaluating inter-professional ethical competencies is an applicable tool in the Iranian context.

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Breaking bad news is an unavoidable part of the medical profession, and doctors and patients stand at the two sides of this function. There are different views about how to break bad news in different cultures and societies. In this study we assessed the viewpoints of hospitalized patients on how to break bad news. This cross sectional study was performed in 2011 at the Jahrom University of Medical Sciences. Sample size of 110 patients was calculated and the method of sampling was simple random sampling. Target population was the hospitalized patients of Peymanyeh and Motahari hospitals in Jahrom. Entry criteria consisted of being admitted to the above hospitals, and exclusion criteria included severely ill patients and patients with mental disorders. A reliable self-administered questionnaire was designed and validated. The questionnaires were completed and returned by 110 patients. Data were analyzed using the SPSS16 software through descriptive analysis. One hundred and ten patients were included in this study. The factor analysis showed three elements: methods of breaking bad news, the people involved in the breaking bad news process, and timing and location. Of participants 78% wanted to be told the bad news while their relatives were present, 63.2% wanted to be told the bad news in a private and quiet room. Almost all respondents emphasized the need for religious advisors and psychological counselors (77.2% and 62.5% respectively). Most of participants (91.5%) wished to receive all the information about the etiology of their disease, and 74.8% of them wanted to be told whether their illness was cancer.This study showed that there are different views on how to break bad news in different cultures and societies. Social and cultural differences must be considered in breaking bad news. In our country, patients’ families could have a prominent supporting role in the delivery of bad news to patients.

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One of the most important issues in nursing ethics is moral distress, which is a severe psychological problem among nurses. The purpose of this study was to determine the nurses’ moral distress in the hospitals of the northwest of Iran.This was a cross-sectional study in which 418 nurses were selected by randomized multistep sampling method in the northwest of Iran in 2012. Data collection was done using the moral distress standard scale with high reliability and validity. In order to analyze data, descriptive (mean, standard deviation, frequency and percent) and inferential statistics (independent t-test and one way ANOVA) were used.The mean score of nurses’ moral distress was 148.49 ± 32.93, and 222 nurses (53%) suffered from severe moral distress. Of the three provinces under study, Zanjan (152.46 ± 35.88) and intensive care units (152.72 ± 33.36) had the highest moral distress scores. Among the respondents’ demographic characteristics, province (P < 0.01), education (P < 0.05), type of shift (P < 0.05) and job status (P < 0.05) were significantly related to the level of moral distress experienced by the nurses.Due to the high level of moral distress in the nursing profession, dealing with it requires a lot of attention. Studies on casual and predictive factors in different wards and teaching coping strategies to nurses appear to be necessary in order to address this issue.

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Lack of knowledge of the medical team about the regulations and laws of abortion can endanger mother’s health and also faces the medical community with serious problems. The aim of this study was assessment of knowledge and viewpoint of midwifery students in Tabriz Azad Islamic University and Tabriz University of Medical Sciences toward abortion. This study is a descriptive study which was conducted in 2013 on 300 midwifery students in Tabriz Islamic Azad University and Faculty of Nursing & Midwifery at Tabriz University of Medical Sciences. A four-part questionnaire was used for gathering data parts 1 to 4 included the personal, social, educational particulars of midwifery students and studying the students’ knowledge about the I. R. Iran’s regulations and laws regarding abortion, studying the students’ viewpoints toward legal and illegal abortion. Our study showed that 26.7% of midwifery students have proper knowledge about abortion, the knowledge of 53.7% of them was in the medium level and 19.7% of students have weak knowledge toward it. The positive viewpoint toward legal abortion was observed in 89.3% of the students and 10.7% of students had negative viewpoint. Our analysis showed that there is no statistically significant difference between students’ knowledge about abortion (P≤0.76), students’ viewpoint toward legal abortion (P≤0.44) and students’ viewpoint toward illegal abortion (P≤0.081). Although in our study midwifery students’ knowledge about abortion regulations was not sufficient, there is the high probability of their encountering with judicial problems. Therefore, it is recommended to raise the midwifery students’ level of knowledge about the authorized cases of abortion and regulations which may decrease the fines of criminal abortions in the future.

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Moral dilemmas caused by modern diagnostic and therapeutic advances in medical science have increased the need to address medical ethics a hundredfold. Medical ethics is a "science", so the method needs scientific work. In order to achieve the objectives of any science, we need to define and resolve the ambiguities surrounding it. Notwithstanding the definitions presented in conjunction with the science of medical ethics, still some issues remain unclear about it.An important part of our knowledge consists of the answers to what things are, and that is nothing but definitions. Definitions comprise the bulk of our perceptions and therefore need to be employed.This review article is the result of a descriptive study. The data were collected through studying credible textbooks and searching internet resources and related articles. While emphasizing the need to clarify the definition of science and characteristics of logical definition, this paper evaluates some of the definitions of medical ethics and by showing their weak points, notes that there is a need for a logical definition of this science and the necessary consideration

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Moral intelligence is one of the dimensions of intelligence that can provide a framework for the proper function of man, and be used as a predictor for people’s conduct. Nurses’ performance is of great importance because of the moral and human nature of their profession, and their adherence to ethical principles improves the nursing care quality as well as organizational performance. Therefore, the present study aimed to assess moral intelligence in nurses.This cross-sectional study was conducted on 400 nurses from teaching hospitals in South Khorasan. Participants were selected through census method. Data were collected by Lennik & Kiel’s moral intelligence questionnaire, and data analysis was performed using SPSS 16 software and descriptive and analytical statistics tests. The results suggest that the nurses’ moral intelligence score was 4.35 ± 0.56 (range: 1-5). There was a direct and meaningful relationship between moral intelligence and age and years of practice (P < 0.05).Optimal levels of moral intelligence suggest the importance that nurses attribute to moral values, and can also be an indirect manifestation of their moral conduct in healthcare environments.

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Self-citation is a behavior that is seen to varying degrees in researchers, research centers and medical journals. The question is whether self-citation is moral or not. This is a descriptive and analytical study (library and document research). Two main keywords (self-citation and ethics) were used for searching databases. In addition, efforts have been made for moral evaluation of self-citation by review articles from databases, ethical-codes and related guidelines.When self-citation is employed to drive readers to a better and easier understanding of an article, it is acceptable and even necessary, but when it is done mainly to increase reference to one’s articles, it is non-essential. Since unnecessary self-citation could mislead researchers and policymakers, bring false prestige for individuals, institutions and magazines, and create unhealthy competition among researchers, it is immoral. Moreover, forcing authors to use an article as reference without a scientific reason is wrong and unethical practice.Modification of evaluation methods for researchers, magazines and research centers to eliminate self-citation and also appropriately informing them about the ethical aspects of unnecessary self-citation could be effective in reducing this phenomenon. It is recommended to observe and inform the rate of unnecessary self- citation among authors, research centers and journals.

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Do not resuscitate order (DNR) is one of the most challenging issues in end of life care. The attitude of health care providers has an important role in legalization of this procedure. The aim of the present study was to investigate the viewpoints of nursing students on DNR orders. One hundred and eighty six nursing students from Tabriz University of Medical Sciences (TUOMS) and Kurdistan University of Medical Sciences (KUMS) participated in the present study. Data collection was performed by Attitude on DNR Order Questionnaire that consisted of 25 items. The results showed that nursing students have a negative attitude toward many aspects of DNR orders, had many misconceptions about this procedure and tended to acquire more information about it. Also, students reported a negative attitude about passive euthanasia and reported that cultural and religious factors are important in their attitude toward DNR orders. Moreover, there was no statistical difference between the attitudes of nursing students from these two universities with two different cultural and religious backgrounds (P > 0.05).Considering the lack of knowledge of nursing students about DNR orders it is suggested that nursing students should be educated on the subject. Due to little research evidence conducting further studies is recommended.

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Abortion is a challenging issue. It is proposed as a problem in medical philosophy and medical ethics texts. In dealing with abortion, graduate medical students may be influenced by different situations, or make a decision according to their conscience. Therefore they should acquire a satisfactory level of ethical development to deal with these issues during their years of education.Some things that are important for education on abortion are law, religious and moral reasoning, understanding the moral reasoning of people who request an elective abortion and related ethical philosophies. If health providers want to make the right decision and manage the patient suitably, they should be aware of the moral reasoning of the abortion applicant, religious moral reasoning, legal issues, and the ethical philosophies related to elective abortion, so they can do the best thing when dealing with abortion applicants. Sometimes the abortion applicant or the health provider thinks that abortion is an ethical action, but according to religion and the philosophy of ethics it is not. Therefore supporting health may be warranted by educating medical students on ethics as well as religious rules and legal issues.

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Medical ethics is a set of moral values that apply principles and responsibilities to the practice of medicine and is a fundamental part of medical education. The current study investigated the effectiveness of the medical ethics curriculum and the best method for its implementation from interns’ point of view. The current cross-sectional descriptive study was carried out in July 2012. The research tool was a questionnaire developed in the medical ethics department and handed to all interns. The validity and reliability of the tool was confirmed using content validity and internal consistency (α= 0.72) methods respectively. Data was analyzed using SPSS software and reported by the use of descriptive statistics, particularly mode, as a measure of central tendency.Seventy-one interns (60%) responded to the questionnaire, 54% of whom were female and 55% in the second internship year. In response to the achievement rate of expected outcomes such as the extent to which the educational objectives have been reached, and the suitability of content with the needs felt in real clinical situations, modes were all ranked in the ategory of "low". The modes of the responses to the stressfulness of different ethical situations were mainly ranked in the category of "high". To assess the best methods for teaching knowledge as well as medical ethics skills and attitudes, the following were the mode of interns' responses: group discussion (38%) for teaching the basics, and presentation of a case with the solution (70%) for teaching clinical ethics. The most appropriate methods of student evaluation were considered patient management problem and performance evaluation in the ward by 25 (36%) and 21 (31%) of interns respectively.The current study showed the effectiveness of medical ethics curriculum was low and the students requested presenting this course in a more practical way. It would appear that a two unit theoretic course does not have the efficiency to modify students’ attitudes and behavior to encounter challenging ethical situations, and therefore fundamental changes are suggested.

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Medical laboratory services and its clients are somehow different from services of the other sectors in the health system. Patient’s Rights Charter, published by the Ministry of Health and Medical Education, was comprehensive, but addressing specific aspects of the related areas in medical laboratories could promote the commitment and dedication in laboratory professional services hence, development of the Patient’s Rights Charter in medical diagnostic laboratories was put on the agenda. After a comprehensive review of existing references and resources, a committee was formed consisting of representatives of laboratory associations and experts in this field, and the draft was prepared. Thereafter several meetings and workshops were held and the members of legal organizations, medical ethics experts as well as laboratory stakeholders, technical staff and laboratory directors attended these gatherings where the draft was surveyed and comments were received. The draft underwent some changes and was edited. Finally in August 2012, the charter was approved by the Health Policy Council of the ministry and in October 2012 was officially announced by the health minister.To be consistent with the context of the Patient’s Rights Charter, essentials of this bill have been based on 5 pillars: access to appropriate laboratory services, access to information in a sufficient and effective manner, the right to choose and decide freely, respect for customer privacy and the principles of confidentiality and integrity, and availability of an efficient system for investigating complaints and suggestions.Developing and delivering the bill of rights for health services recipients is one of the foremost matters, but implementation of the provisions of the charter and monitoring of its effectiveness are the most important goals ahead. Therefore, an effective strategy to implement the rights of patients in medical laboratories should be designed and established.

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Assessing nursing students’ level of respect for ethical codes of nursing is essential as these students are the future health care providers. There is a need to check observance of ethics codes among students, because that will determine ethics education and training needs. This study aimed to assess nursing students’ compliance with professional ethical codes and some of the relevant factors.This is a descriptive-analytic and cross-sectional study performed by census on 118 nursing students who were training in hospitals of Shahid Beheshti University of Medical Sciences. The data gathering tool consisted of a questionnaire including demographic information, and another questionnaire which was developed by the researcher based on studies in Iran and throughout the world.The ethical codes that were respected most included "principles of conflict management" and then "respect for the medical staff". "Respect for patients' rights" and "patient education" received less consideration. Grade point average, gender, marital status, interest in nursing and likelihood to work in nursing had significant association with respect for ethics codes.The results of this study can be used in developing courses on nursing ethics and educating nurses on the subject, and could be of special interest to health planners and policy makers.