Iranian Journal of Medical Ethics and History of Medicine

---

---

---

---

Although there is no more propensity for measuring patient's satisfaction as an important qualitative scale of health services, the thing which is slightly seems to be forgotten is the attention towards the concept and expansion of theory framework. The purpose of this study is to remark the meaning of satisfaction and to offer a qualitative definition for that. This research is a qualitative study and content analysis. During the study period  fifteen patients who were hospitalized in Semnan hospitals (2009) were selected. The data were gathered by half-structured interview and analyzed. The results of this study shows four two major themes and four subthemes including feeling of satisfaction and the reception of nurses by patients. Accordingly, satisfaction is a calm sense that the patient feels it after the emotional and logical reception of nurses. The feeling will be sensed by intelligent and sometimes emotional feeling of patient towards the nurse in his/her care unit environment. The results of this study indicate the real and basic meaning of patient's satisfaction from nurses' views. This meaning is even beyond the imagination of experts and managers. These results can be put into work for designing suitable tools to measure the scale of patients' satisfaction of nurses based on their real perception.

---

By the ever-increasing discovery of pharmaceutical and chemical substances, their  adverse effects  will be considered too. To evaluate adverse effects, animals are used, and factors like standardization of species and breed, storage condition and biochemical system will be effective for animal selection. In Islamic education, animal issues are important. The principles of keeping animals, using them and prohibition of animal abuse are mentioned in this article. The information were gathered from electronic and non-electronic resources including articles and books. Based on this, the following issues need specific attention:

• 1- Infrastructure of rights: In Hajj and Nahl chapters of Quran (verses 18 and 49) it is mentioned that animals will bow down to God. This is the basis of animal rights.
• 2- Animal rights for keeping them: For this case Sheikh Tousi and martyr Saani mentioned that it is necessary for the owners to feed and water the animals enough.
• 3- The exploitation rights: In the Holy Quran, it is said that the power and the hygiene of the animals must be considered and it is major to exploitation.
• 4- Rights of animal's damages: It is advised to keep and defend the animal species and human beings are forbidden to harm and kill animals. Therefore, from Islam point of view, although animals lack the speech power, they must be treated emotionally and their owners have some responsibilities, too.

---

The medical Arjuze is one of the less known works of Avicenna, a great Iranian scientist and physician, which is written didactically in Arabic. In this book, Avicenna has composed 1326 lines about a complete cycle of traditional medicine of Iran in Arabic in the form of battle cry. Didactic poetry is one of the poetry forms which its main purpose is to provide educational aims and to convey scientific terms both in literature and poetical way. Avicenna's poetry in Arjuze is simple and fluent. The medical topics are overviewed in a sketchy way and not in full details in this book. In this book, theoretical and practical medicines are explained in two specific parts.
The existence of French and English translations of Arjuze shows the value of this work for Europeans as a complete outline about medicine in that time, but there is no Persian translation of this work, available. Traditional Medicine and History of Medicine Research Centre of Shiraz University of Medical Sciences has started the translation of medical Arjuze with the aim of introducing this precious work which shows the educational pattern of traditional Iranian scientists in using didactic poetry.
The purpose of this article is to introduce the characteristics of Avicenna's Arjuze with an overview of his position in modern traditional medicine.

---

Brain death is a subject in our society which can be mistaken with coma or other types of life status similar to death. To assess the legal status of a brain dead patient, it is necessary to determine whether a person afflicted with brain death is dead or alive. Do they meet the criteria for biological death? Or in precise words, do Islamic laws for the dead apply to them? Several questions arise in this regard, which give more importance to this issue from the viewpoint of Islamic jurisprudence and law, and all answers depend on our definition of brain death, and whether we find brain death an instance of the separation of body from soul. There has been much research around this issue and the laws in many countries and religions, including Christianity and Judaism, have been disambiguated. In Iran, however, brain dead patients are considered alive, while brain death should be legally considered absolute death like in many medically advanced countries (UK, Germany, France, and USA). The authors aim at examining this issue from the viewpoint of Fiqh and law, and its disambiguation.

---

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.

---

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.

---

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.

---

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.

---

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.

---

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.

---

Evaluation of the factors related to the patients&apos complaints against medical staff, especially doctors and efforts towards its reduction affects patients&apos satisfaction of health care system.  The main purpose of the present study was to determine the factors related to the patient`s complaint against doctors with the verdict of Medical Council of Kerman.
This study was a descriptive, analytical and practical evaluation, assessing 250 documents related to the patients&apos complaints of doctors in Kerman Medical Council during 2004-2009.
 The most reasons of complaints (%73.2) were carelessness and disrespecting scientific and legal standards, and obtaining funds out of legal standards (%9.3) respectively. In the case of issuing vote, the most opinions (%31.7) were innocence and suspended and barred from prosecuting (%22.9) respectively. Most complaints were of ophthalmologists and private hospitals.  There were significant relationship between the reason of complaint and issued out (P<0.01, c²= 53.706) and the reason of complaints and field practitioners (P=0.026, c²= 49.27). No significant relationship between issued out and the type of hospital was found.
Regarding the results, respecting scientific, and legal standards, and decreasing financial relationships between doctors and patients is an effective way in reducing patients&apos complaints of physicians. Improvement in physicians&apos patients&apos relationship by explaining the disease condition, its risks and treatment options to patients are effective in reducing patient&aposs complaint against physicians.

---

Caring for dying patient is one of the painful events and a tough experience for nurses. Care of dying patient according to his/her cultural norms is one of the principles of nurse's professionalism. Therefore identifying and explaining the daily experiences of nurses in cultural care of dying patients would help in determining caring standards. Due to the lack of such studies, the aim of this study was to explain the nurses' experiences in the care of dying patients.
This study is a qualitative investigation with content analysis method. Eighteen nurses working in teaching hospitals of Tehran were selected by purposeful sampling method from 2010 to 2011. Data were collected through semi-structured face to face interviews. Content of the interviews were transcribed and analyzed by content analysis.  
The findings were classified into two themes of cultural exposure and cultural skills.  Understanding of family presence and family bereavement were two sub-themes of cultural exposure.  Cultural skills consist of 3 sub-themes i.e., preparation for telling bad news, facilitating facing death and solacing family members. 
Regarding our results, in order to meet patients and their families expectations in a respectful manner, nurses awareness of cultural norms of the dying patient and his/her family seems to be necessary. It would be an important step in reforming and improving nursing performance and professional development.

---

The aim of this study was to explore experiences of family members of patients confronting brain death diagnosis and the request for organ donation.
A qualitative study was designed focusing on content analysis. Data collection process included 38 unstructured in- depth interviews with relatives of 26 brain death patients who were candidate for organ donation and field notes. Sampling method began as purposive and continued as theoretical until saturation.
Five main themes were extracted from the current dataset that indicated family experiences and perceptions of brain death concept while being informed. The themes were included internal conflict, internal barriers against external realities, imminent sense of loss and grief, surrender and acceptance.
The results showed that facing the diagnosis of brain death for relatives and family members is a condition surrounded by many challenges, ambiguities and conflicts that is become more complicated when emotional responses related to grieving and defensive psychological reactions emerge. So it is recommended before any organ request, at first medical team provide conditions for brain death acceptance. Respecting family members experiences and their perceptions about the situation will resolve their internal ambiguities and conflicts. At this situation requesting organ donation seems to be rational.

---

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.

---

The main challenge in organ transplantation is the organ limitation. According to the law of organ donation, it's necessary to obtain family consent for organ donation from a brain-dead patient in addition to patient consent. In this research, we explored Tehran citizens' viewpoints regarding organ donation from beloved ones in case of brain death.
In this cross-sectional study, two interviewers selected 706 study participants by phone interview through random digit dialing during February to November 2010. Calls were made between 6 and 9pm on 5 workdays. Companies and organizations were excluded from the study. Only those over 18 year of age were enrolled in the study.
Of 1379 people who met the inclusion criteria, 706 subjects agreed to have the interview (response rate=51%). Of these, 83.3% (n=688) agreed with organ donation from family member if they had a donor card and suffered brain death. Agreement with organ donation was significantly associated with considering brain death to be real death (P=0.011) and considering it to be irreversible (P=0.028).
In conclusion it is necessary to design public education programs to change their misconceptions about brain death, and provide options to opt for organ donation in case of brain death on common cards such as drivers' license so that family members can make decisions about organ donation more easily when a beloved one suffers brain death.

---

Because of complications of medical treatments, informing patients about the rate of treatment success, potential risks, and side- effects, is considered as an indispensable part of treatment contracts. Patients' deprivation of this information can be considered as a major obstacle in obtaining informed consent. Clearly treatment without patients' or their legal guardians informed consent may lead to civil and penal liability for the physicians.
Consenting without getting enough information about the disease, and its treatment is the most important issue in this regard. Now can such consent be valid and legalize the treatment or not? In this article informed consent and the physicians duty of informing patients are compared in three legal systems of Iran, England and France and then the physicians' duty of notification will be analyzed and some suggestions for safeguarding patients rights will be offered.

---

Quality of nursing care services directly influences individuals' health status. Compiling codes of ethics according to the religion and culture of each population could be an appropriate approach in improving quality of health care services especially nursing care. Hence, the most important priority in our national health system is developing ethical guidelines.
For this purpose a task force has been established in collaboration with nurses, physicians, lawyers and clergymen who were expert in the field of medical ethics. The code of ethics for Iranian nurses was drafted in 2010. The draft that included 12 values and 71 regulations of professional ethics were finally approved in the second session of the Ethics Supreme Council of the Ministry of Health and Medical Education on 6 March, 2010.
The values consist of concepts such as maintaining human dignity, adherence to professional obligations, accountability and responsibility, patient privacy, promotion of scientific and practical competence and respect to individual's autonomy.
Also, 71 regulations of professional ethics divided to five sections including "Nurse and Community" consisting of 9 items, "Nurse and Professional Commitments" with 14 items, "Nurse and Clinical Services" with 23 items, "The Nurse and Other Healthcare Providers in Medical Team" with 15 items, and also "Nurse, Education and Research" including 10 items.