Iranian Journal of Medical Ethics and History of Medicine

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Euthanasia or mercy killing is a new and challenging topic in medical law. This article examines all types of euthanasia based on the Islamic criminal code of 2011, and demonstrates that active and involuntary euthanasia is murder if conditions exist the basis for active and voluntary euthanasia, however, is the victim’s consent, so the penalty is less. As the physical element of inactive euthanasia is omission, clause 296 of the criminal code and clause 2 of the penal code on refusing to help the wounded apply. Lastly, it is suggested that legislators criminalize euthanasia with a new approach and independent title, and consider principles of justice to determine less punishment for this type of killing compared to murder with malice aforethought.

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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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Patient's refusal of treatment is the rational consequence of informed consent and is considered among the patient's rights but can lead to patient harm or harm to others, or damage to the health care system. Major ethical challenges in the field of treatment refusal arise from capacitated patients. This paper mainly examines theoretical issues related to this group by reviewing books on jurisprudence, philosophy and bioethics, especially textbooks that include moral philosophers' perspectives, the views of experts in bioethics and jurisprudential considerations related to this issue. These views sometimes are very different or in conflict with each other. Based on different schools of philosophy or ethics, our encounters with patients who refuse treatment can range from abandoning patients on the one hand to treating them at any cost, even by coercion or deception on the other hand. According to Islamic perspectives, people have no right to harm themselves, but because of the authority that each person has on his or her body, this does not mean that compulsory treatment is permitted it means that caregivers must try to persuade patients to accept treatment, and must not cooperate with them to harm themselves and to discontinue treatment specifically.

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Respect for the inherent dignity of human beings means respecting their basic rights in different environments, and this has an important role in studies and discussions about health care. This study was conducted on the development and psychometric properties of the Inherent Dignity Questionnaire (IDQ) in heart failure patients. The present study is a methodological research for designing a questionnaire. First, 22 patients with class II to IV heart failure were chosen by purposive sampling from patients of Hazrate Rasoule Akram, Imam Hossein and Shariati hospitals of Tehran, and semi-structured interviews were conducted on ethical issues until data saturation was achieved. A qualitative content analysis was carried out to analyze the interviews. Then, based on the findings obtained from the interviews, literature, and the designed questionnaires about inherent dignity, 39 items associated with inherent dignity in heart failure patients were developed. The face validity of the questionnaire was determined. To measure the content validity of the questionnaire, opinions of 12 experts were used considering Content Validity Index (CVI), Content Validity Ratio (CVR) and Lawshe table. To assess construct validity of the IDQ, exploratory factor analysis and to determine the reliability of the questionnaire, internal consistency with Chronbach’s alpha coefficient and split-half method were used on 130 patients with heart failure. The data were analyzed using SPSS version 19.Through face validity and content validity analysis, 4 out of the 39 primary items were removed, leaving 35 items. Through exploratory factor analysis, 11 items with factor loading less than 0.5 were removed and the IDQ was created with 24 items and three factors (9 items on the first factor, 8 items on the second factor and 7 items on third factor). These factors were: "inherent dignity in family", "inherent dignity in the community" and "inherent dignity in health care environments". Reliability of the Social Dignity Questionnaire (SDQ) was calculated to be 0.94 by using Cronbach's alpha coefficient, and 0.96 by using split-half method.Results of this study showed that the IDQ is adequately valid and reliable. Therefore, using this questionnaire can be beneficial to planning support for patients and improving their treatment and care and doing further research related to dignity in different patients.

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Considering and preserving patients’ human dignity is one of the most essential moral obligations in the medical and nursing professions. Indeed, respecting patients’ human dignity is the essence of nursing care which is frequently emphasized by national and international nursing standards.This study was conducted based on the qualitative approach, using an interpretive phenomenological method, which aimed to explore the meaning of patients’ dignity preservation based on nurses’ lived experiences. Using purposeful sampling method, a sample of 12 participants was chosen and the data were collected through 16 individual, in-depth and semi-structured interviews. The transcribed interviews were analyzed based on the hermeneutic approach using the analysis method proposed by Diekelmann, Allen and Tanner (1989). The mentioned interviews continued until no new meanings emerged and until the researchers were satisfied with the depth of their understanding. Through fusion of the horizons of the participants’ lived experiences and the researchers’ pre-understandings, the extracted meanings of patients’ dignity preservation emerged as: “respecting the equal human essence”, “providing professional patient-centered care” and “respecting the rights of patients’ companions”.The findings revealed that it is essential to respect the patients’ and also their companions’ rights and recognize the humanness and individuality of each patient for preserving and promoting patients’ dignity and providing more dignified care at the bedside.

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Refusal of medical treatment is among the most important rights of patients and a natural consequence of informed consent, although it can result in harm to patients or others and even the health care system. Treatment refusal may have various clinical manifestations whose recognition and proper understanding is essential to their management. In some cases the legal aspect is primarily dominant, such as when there is the possibility of harm to a third party. In other cases, for instance in absence of patient capacity, there are clear guidelines for decision-making. Major ethical challenges in the field of treatment refusal frequently pertain to capable patients, and this paper is mainly about the practical issues related to this group. The problems that these patients face are mostly due to improper physician-patient relationship or fleeting emotions. Caregivers should be prepared to deal with these issues and try their best to overcome obstacles and achieve patient satisfaction, with the exception of critical emergencies where treatment is carried out without consent. If all measures fail, patients’ refusal must be documented and other therapeutic interventions should be offered.

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Patient autonomy is the opposite of paternalism and an essential element in individualised, patient-centred, ethical care. Challenges associated with patient autonomy are culture-related and have not been fully investigated in Iran so far. The aim of this study was to explore the challenges to the autonomy of patients in Iranian hospitals.This was a qualitative study using conventional content analysis methods. In 2013 13 patients, 7 nurses and 1 doctor were selected from three Tabriz and Hamadan teaching hospitals using purposive sampling to participate in semi-structured interviews. The interviews were subjected to qualitative content analysis and analysed using the MAXQD10 software.Fifteen categories and three themes were identified. The three main themes related to challenges associated with patient autonomy were: interpersonal factors, altered relationships, and organisational constraints. In summary, this study revealed some challenges associated with patient autonomy that the treatment team, managers and planners in the health care system should target in order to improve patient autonomy.

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Breaking bad news to patients and their families is an important issue in health care services. Since access to information is among the basic rights of the patient, investigating the experiences of patients and their families after receiving bad news can make the process more purposeful and prevent unnecessary suffering. This study aimed to describe the experiences of patients and their families after hearing bad news from health providers.The present study was conducted with a qualitative, phenomenological approach. Participants were selected through purposive sampling from people who had the experience of receiving bad news during 2013 in Birjand, Iran. The sampling process continued up to the point of data saturation, which reduced the number of participants to 10. Note-taking was used to complete the data collection process. In this study Colaizzi's method was used for data analysis, while robustness of the study was assessed based on the criteria of precision.The subjects were between 25 and 70 years of age. First, according to Colaizzi's Method, 280 codes were obtained which were the same as the developed concepts. At this point, the code lists were extracted. Different thematic categories with similar meanings were placed in 5 thematically larger groups as follows: 1) tension at the beginning of the encounter, 2) adaptive responses, 3) spiritual relief, 4) family crises, and 5) seeking support.Patients and their families showed different reactions upon receiving bad news. The study showed that health providers can contribute to a better adjustment of patients and families and promote peace by acquiring a methodical approach while delivering bad news. This can be achieved by identifying the reactions, confusions and tensions, as well as introducing adaptive or supportive resources to patients and their families.

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Patient advocacy is an inherent element of professional nursing ethics that helps to protect the patient’s rights. Many codes of ethics in nursing are concerned with this particular role of nurses. The present study aimed to evaluate the protective advocacy beliefs and actions of the nurses employed in educational hospitals affiliated to Birjand University of Medical Sciences during 2014. Data in this cross-sectional study were collected using a demographic characteristics questionnaire and the protective nursing advocacy scale. Participants included 248 nurses working in six hospitals located in Southern Khorasan province selected by randomized stratified sampling. The Cronbach’s alpha for Protective Nursing Advocacy Scale was 0.74. Data were analyzed in SPSS version 16 using descriptive and inferential statistical tests.Moderate levels of protective advocacy were observed in the majority of participants (80.6%), with a total mean score of 137.39  13.65. Some of the protective advocacy components had significant correlations with age, work experience, type of ward, employment status, and history of participation in ethics education programs (P < 0.05). In other words, the total mean score of advocacy and some of its components were significantly higher among nurses who had attended ethics education programs than those who had not (P < 0.05). Moreover, nurses who were older had more work experience, had worked in the emergency ward, and had a permanent employment status had higher scores of advocacy than others. The total mean score of advocacy among the nurses in this study was relatively appropriate, although strategies are needed to improve the score. It can also be assumed that nurses’ involvement in ethics education programs can increase the level of nursing advocacy. On the other hand, changing nurses’ temporary employment status to permanent status and providing job security for them may reinforce protective advocacy beliefs and actions in nurses.

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Respecting patients’ privacy leads to increased satisfaction among hospitalized patients and can accelerate the healing process and reduce hospitalization time. This study aimed to determine the level of respect for patient privacy in the teaching hospitals of Zanjan city during 2012. In this cross-sectional study 256 hospitalized patients were selected by multistage sampling and completed the study questionnaire. The questionnaire consisted of two parts: the first part collected the participants’ demographic data and the second part examined the various aspects of patients’ physical privacy. Data were analyzed using SPSS version 21. The results showed that most of the samples (76.2%) were unaware of patients’ rights, and about half (49.2%) believed that their physical privacy was respected most of the time. Meanwhile, 56.3% of the patients declared that medical team members never closed the curtains during physical examinations and medical procedures. The mean score of observation of privacy was less for single patients (51.23 ± 14) compared to married patients (58.88 ± 13) (P <0.05). Based on our findings, most patients were not aware of their rights and some measures of physical privacy were not observed. Therefore, authorities must pay more attention to systematic planning in order to ensure that patients’ privacy is respected in all areas of health and education.

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Nowadays, electronic communications technology propounds new forms of the patient-physician relationship in the field of medicine. Effective communication between the patient and the physician can play a crucial role in the process of treatment. This new form of communication greatly influences promotion of the health system by improving access to inexpensive and fast services regardless of geographic boundaries. In times of crisis, telemedicine plays an important role in delivering health services to deprived areas in a just manner. Usage of communications technology is inevitable, and due to the virtual nature of this kind of medical communication, recognition of certain ethical considerations seems essential. Successful examples of telemedicine are abundant throughout the world and usage of this technology is a helping solution for inadequacies in the healthcare system. In Iran, because of the geographical extent of the country, this technology can provide access to medical services in some cases.In order to achieve the best outcome in telemedicine, it is essential to respect confidentiality, privacy, informed consent and commitment to professionalism in this field.

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Medical laboratory is one of the health service providers that intensely responsible for the life of patient / client. With an increase in the number and variety of laboratory tests in recent years, the role of laboratory science in identifying and assessing the cause of disease has been more recognized. Performing the laboratory tests with the utmost accuracy, precision and speed using up to date methods as well as protecting the rights, integrity and respecting human dignity and also the establishment of priorities and the requisites for quality management systems can have a significant impact on patient satisfaction and quality which are the characteristics of a good medical laboratory. The principle concept of doing good and not doing bad is the essence of every code of medical ethics. Therefore, in laboratory medicine like other areas of medical sciences, there are ethical questions that have become more complex with the development of diagnostic tests. Medical laboratory practitioners usually deal with issues of confidentiality of patient information, as well as issues related to research ethics, professional ethics and business ethics.This study has collected important and common topics of medical ethics in laboratory medicine which leads to increase readers’ and practitioners’ information in this field. It is hoped that such information could be effective and practical to improve the laboratorial services for patients.

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Ethics is important in all professions, particularly in nursing, since morality and commitment in nurses can play a significant role in improving patients’ health and recovery. The nursing profession is therefore rooted in ethics, and the observance of nursing ethics is more important than other aspects of health care. This study aimed to determine patient's views on standards of professional ethics in nursing practice in Imam Hussain Hospital during 2015.

This was a cross-sectional study conducted on 575 patients in different wards of Imam Hussein Hospital in Shahroud. Research instrument was a 22-item questionnaire designed by the researchers to evaluate nurses’ observance of professional ethics in the three dimensions of accountability, improvement of care quality, and respect for patients. Data analysis was performed using SPSS 20 software.

The mean age of participants in this study was 51.32 (± 19.03), and 299 participants (52%) were male. The mean total score of professionalism was 18.38 (± 2.74), and the relationship between age and observance of professional ethics was statistically significant (P = 0.006).

According to the subjects of this study, the nurses’ observance of professional ethics was relatively good and at a desirable level. It is recommended to utilize a variety of learning styles and employ the services of professors of nursing ethics in order to enhance the quality of nursing education with respect to professional ethics.

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Observation of patients’ rights as a major component in defining the standards of clinical services can increase patient satisfaction and is an important indicator of health care quality. Since most hospital patients are admitted through the emergency department, this study was conducted to investigate the observance of patients’ rights in the emergency department of Nemazee Hospital during 2015.

This cross-sectional study was performed on 100 patients over a period of one month. Data were collected by a questionnaire and analyzed using SPSS version 21 and statistical tests including descriptive statistics and inferential analysis.

The mean of the patients’ age in this study was 54.4 ± 19.35. Based on our findings, the overall level of observing patients’ rights was 51%, while patients’ expectations were 93%. Moreover, there was a meaningful difference between observance of the patients’ rights and their expectations in all aspects based on the paired sample t-test (P<0.05). It was also established that age was one of the factors affecting observance of patients’rights (P<0.05).

In this study, observation of patients’ rights in the emergency department was at the intermediate level, while patients’ expectations were higher in comparison.

In order to promote patient satisfaction, it seems necessary to educate the personnel and medical students on patients’ rights by holding workshops, reducing the waiting time for receiving services, and establishing an order in the system based on the patient’s condition.

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Nurses comprise the largest group of service providers in the health system and have a significant impact on health care quality; therefore, ethical practice is of greater importance in the nursing profession compared to other fields of care. The present study was conducted to evaluate patients’ views on nurses’ observance of professional ethics in training hospitals of Bushehr during 2015.

This was a descriptive cross-sectional study performed on 208 patients hospitalized in teaching hospitals of Bushehr selected by convenience sampling. The research instrument was a questionnaire including demographic characteristics and questions about ethics of the nursing profession. Validity and reliability of the data collection tool were approved. Data were analyzed through descriptive statistics, t-test, ANOVA and Pearson’s correlation coefficient using SPSS version 18.

The results showed that 94.6 percent of the patients evaluated the nurses’ observance of professional ethics as good, 4.4 percent as moderate and 1 percent as poor. Moreover, no significant relationship was found between the independent variables of age, gender, marital status, education level and history of hospitalization ward in the patients, and their views on nurses’ observance of professional ethics.

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Physician-assisted suicide is an important, challenging issue in medical ethics, which the right to die is a central point in this issue. Physician-assisted suicide is offered to end intolerable pain and suffering. Although, it is a legal practice in some countries, still it is a challenging and controversial practice in ethical and legal perspectives. It has been argued that based on the principles of medical ethics, physicians should respect patient’s decision, however many ethicists and jurists believe that Physician-assisted suicide is unethical. It should be noted that the main reason for proponents and opponents is based on their interpretation about human dignity. This controversy can be resolved by reference to religious interpretation of human dignity in which asserts that Physician-assisted suicide is against human dignity and respect for human life.

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Nursing is an ethical profession and nurses are responsible for patient care. In providing healthcare services, patient right is an important issue to consider. However, not only the awareness the patient right is important but also moral sensitivity to ethical decision-making is crucial. This study aimed to determine the relationship between moral sensibility and attitude towards patients' rights. A descriptive-analytic study was used and 194 nurses working in intensive care units in hospitals affiliated to medical university of South Khorasan province were selected by convenience sampling method. The data collected through a questionnaire consisting of three parts: 1) demographics 2) the moral sensitivity questionnaire (Korean version), and 3) a questionnaire survey of nurses' attitudes towards the patients’ rights. Data collected by the software SPSS version 16, and were analyzed descriptive and analytical statistical tests.

The results showed that there is a significant direct relationship between average moral sensibility and nurses' attitudes towards patients’ rights (r= 0.6, P=0.03). The average nurse's ethical sensitivity has been reported 3.05±0.68 0f the total score (0-4). The average attitude towards the patients’ rights was 4 ± 0.8 of the total score (1-5). The relationship between moral sensitivity whit the years of service and age of the participants was significant (P<0.05). There was also a significant relationship between the attitudes of nurses towards patients' rights with gender and years of service (P<0.05). In conclusion it is necessary to provide more moral education to increase nurse’s moral sensitivity towards patients’ rights. It should be noted that due to the fact that moral sensitivity and attitude towards patients' rights increases with the number of years of service the article suggests that considering more experienced nurses in the teams would result a more morally sensitive care for the patients.

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The cultural competence, responsibility and ethical beliefs are influential factors in providing quality services by nurses and pay an important role in patient's right. The purpose of this research was to illustarte a predictive model of patient's right based on cultural competence, responsibility and ethical beliefs. The research method was correlational study conducted in 2016 among 300 nurses in west Azerbaijan in 2016, selected by multistage cluster sampling. For gathering the data, the Perng and Watson’s nurses’ cultural competence questionnaire, and the Mergler and Shield responsibility questionnaire as well as the Mahmoudi and et al questionnaire on ethical beliefs and Scale rights of patients were used. The data were analyzed by using Pearson correlational coefficient and bootstrap through SPSS software and amos-22. The results indicated that the model was fitted and has direct effect in cultural competence (0.11), responsibility (0.57) and ethical beliefs (0.24) on nurse’s attitude with the rights of patients were significant. The indirect effects of cultural competence (0.03) and responsibility (0/03) with mediating of forming the model of ethical beliefs were significant. In conclusion, %65 of the variance in nurses’ attitudes to the patients' rights was determined by the variables of this research model. Due to the direct and indirect effects of cultural competence, responsibility and ethical beliefs on the attitudes of nurses towards patients' rights, it is important to increase cultural competence relationship and responsibility with nurses’ attitudes towards   patient’s rights by focusing on ethical beliefs.

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Privacy and confidentiality are the inalienable rights of every human being to preserve his dignity. This issue should be considered in all levels of medical interventions. In the healthcare system, based on respect for privacy and confidentiality, patients decides what information to provide to their physicians. However, if a patient does not provide necessary information to his physician this may impact the diagnosis and treatment. This study aims to evaluate patients’ attitude regarding privacy and confidentiality in healthcare delivery. The result helps policy makers to establish appropriate relations between healthcare providers and patients by realizing its strengths and weaknesses.
This cross-sectional study was carried out on 200 patients, selected in a systematically random way, in Imam Khomeini and Shariati hospitals in Tehran the capital of Iran in 2010. The data were collected directly from patients by trained interviewers based on a questionnaire survey. In order to analyze the data based on the scores of the attitude, patients’ attitudes were classified into three groups of negative, slightly positive, and positive and were evaluated by using various statistical tests.
In result, 56.5% (113) of participants were females and 43.5% (87) were male. In this study, it was found 71 (35.5%) patients were “strongly agree” that male physician can examine female patients and 99 (49.5%) patients were “agree”. Fifty three patients were “strongly agree” that physician may consult with his assistant through training (without the patient's permission) and 103 patients were “agree”. Participants’ attitude about disclosing the patient’s information if a he has threaten self-harm or harm to another person was as follow, 45 (22.5%) patients were “strongly agree”, 82 (41.0%) patients were “agree” and 56 (28.0%) patients had “no comment”. In this study, in general 36 (18.0%) patients had “negative”, 162 (81.0%) patients “slightly positive”, and 2 (1.0%) patients had “positive attitude” towards privacy and confidentiality in healthcare settings.
In conclusion, the study population possessed a moderate attitude towards privacy and confidentiality. These results show that in addition to performing further studies, patients’ attitude towards privacy and confidentiality should be adequately improved.
 

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