Iranian Journal of Medical Ethics and History of Medicine

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The first step in battling against prevention and control of a social phenomenon is to distinguish it completely and clearly. Designing the information system of substance abuse, with the aim of converting data into information and knowledge, consists a great share in prevention and control of addiction, but it is faced with challenges and problems which have unpleasant and inappropriate consequences on consumer abusers. Therefore, this article is written with the purpose of studying the medical ethics challenges of information system of substance abuse.
The present research is a review of studies. The needed information is gathered form Medline, Ovid, Elsevier, Google and Pubmed search engines and also from Police Information and Statistic Centre, Ministry of Health, and Medical Education, Welfare Organization and National drug Studies centre.
Substance abuse information system has several legal and ethical problems that if they occur, abusers will show no zest for receiving any consulting and medical services and also participating in epidemiological studies.
World Health Organization has provided a special framework in eight compasses including respect for human dignity, secrecy and privacy policy, to respond to the health information system.
Before arranging the schedule, designers and programmers of  substance abuse information system should provide and codify the rules, regulations and necessary instructions to clarify and determine the legal status, in order to guarantee the secrecy and privacy policy of information.

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Reporting professional errors is an essential step towards improving patient safety not only in hospitals but also outpatient healthcare centers. Unfortunately, nurses, like many other members of the medical team, do not report most of their mistakes and errors in performance. The objective of this study was to assess possible determinants of the tendency to report nursing errors by exploring the experiences of clinical nurses and nursing managers in this regard. In this qualitative study, 115 nurses employed by hospitals and specialty clinics of Tehran and Shiraz Universities of Medical Sciences were enrolled. Data were collected through 17 sessions of semi-structured discussion groups, and contents were examined and analyzed based on an empirical-analytic approach. The main patterns observed in this study included 1) nurses' overall perception of error, 2) obstacles in reporting nursing errors, 3) motives of reporting error. Reporting errors can provide valuable information for prevention of future errors and improvement of patient safety. Overall, considering the obstacles and motives of reporting nursing errors, there is need for codes and regulations in which the process of reporting error and the components of error are clearly determined and defined.

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Decision making by a surrogate on behalf of incompetent patients is based on the ethical principle of "respect for autonomy". The increase in advanced health services has lead to more instances of decision making for incompetent patients receiving such services, and the treatment team usually asks a family member to serve for this purpose without being aware of the patient's preference. This study was conducted to assess patients' wishes and preferences regarding surrogate decision makers and determinants of such preferences.The study was cross-sectional, and samples were selected randomly from patients presenting at Farabi Eye Hospital clinics who were 18 years of age or older. Questionnaires were completed through interviews. Two hundred patients between 18 and 83 years old were interviewed. About 52% (n=105) were men, and 73% (n=77) were married. Among the married, the spouse was chosen as the surrogate decision maker in only 51% of cases. Among singles, boys preferred their father in 36% (n=9) of cases, while girls chose their father in 5.6% (n=1) of cases and the most frequent choice was other unmentioned people (33.3%, n=6). Most patients (93.5%) wished to be asked about their surrogate decision maker upon admission.Results of this study demonstrated that the people we usually consult for decisions concerning patient treatment are significantly different from patients' preferred surrogate decision makers. We suggest leaving the choice of surrogate decision maker to the patient while they are conscious.

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Admitting medical errors is one of the professional obligations of physicians that unfortunately involves numerous challenges. The present paper aimed to investigate the attitude of surgery faculty and residents towards medical error disclosure and factors affecting it. In this cross-sectional descriptive and analytic study, a self-administered questionnaire was distributed among all faculty and residents of the department of general surgery of the teaching hospitals of the Tehran University of Medical Sciences. The response rate was 84.1% (53 out of a total of 63). Tendency to make minor and major errors among the respondents was 39.6% and 49.1% respectively, and 71.7% declared that the most significant factor hindering error disclosure was fear of litigation. Only 16.7% (8) had disclosed their most recent medical errors to their patients, 25% (2) of whom had to face legal action. There seems to be a clear distinction between the doctors’ inclination to disclose their medical errors and what actually happens in their practice, the most important reason being their professed fear of litigation. Considering the need in the majority of physicians for appropriate training on the subject of medical errors and communication strategies, it seems that in order to resolve this issue, changes need to be made in the current system for error management so as to provide professional support for physicians who make medical errors, and doctors should receive the necessary training on ethical principles and patient communication strategies.

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

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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.

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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.

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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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This study aims to develop a national questionnaire that measures the moral sensitivity of Iranian medical students. The questions were developed based on ethical vignettes in educational documents, the professional code of conduct in Tehran University of Medical Sciences and medical students’ workbooks in ethics course. A pilot study was conducted to evaluate the clarity and appropriateness of 7 primary questions. Next, 38 questions were reviewed for content and face validity by an expert panel including 7 expert teachers and 4 lay experts (medical students). In order to assess the reliability of the finalized 35 questions, a test-retest was conducted on 30 medical students with a 2 weeks interval. Through test-retest study, the median values of intraclass correlation coefficient (ICC), Spearman and Kappa were calculated at 0.81, 0.65 and 0.53 respectively. The final version of this instrument consists of 24 scenarios, each presenting an ethical challenge, and has a Cronbach’s alpha reliability score of 0.67. The final questionnaire could be used as a valid and reliable research instrument to determine the moral sensitivity level of Iranian medical students. Another application for this instrument may be evaluation of the effectiveness of curricular reforms by longitudinal studies. To the best of our knowledge, this is the first context-specific instrument on moral sensitivity assessment in Iranian medical schools.

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Empathy and communication between dentists and patients are among the major concerns of dental health educators. The present study aimed to evaluate the empathy levels of dentistry students with their patients in the city of Tehran during 2014.In this descriptive cross-sectional study, 410 dentistry students of various universities throughout Tehran were selected randomly. Data were collected using the questionnaire of demographic data and Interpersonal Reactivity Index to assess dispositional empathy. Data analysis was performed using SPSS 16 statistical software.The students had a mean empathy score of 53.06 (SD = ± 1.03), with the highest level pertaining to the imagination dimension (14.41 ± 4.65). Age, gender, and educational level had significant relationships with empathy (P < 0.01). Female students reported higher emotional empathy (P < 0.01), but no significant relationship was found between empathy and the university of attendance.Empathy scores of undergraduate dentistry students were lower than ideal and acceptable levels. Therefore it seems necessary to design proper educational programs to improve empathy among dentistry students.

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The present study is an overview of the causes of patient complaints against physicians and the medical staff in Imam Khomeini Hospital Complex, and strategies to reduce the complaints. For this purpose, complaints that had been filed with the clinical governance office of Imam Khomeini Hospital Complex in 2012 and 2013 were investigated. The information in the forms included age and sex of the plaintiffs, their level of education, type of complaint and similar details. Of the 309 complaints, 174 had been recorded in 2012 and 135 in 2013. The plaintiffs were males with a mean age of 50.5, and 69.6% of them had high school diplomas or lower. Most (16.2%) of the complaints pertained to the emergency department, while 48.5% and 22.7% of the complaints were related to doctors and nurses respectively. In 62.5% of the cases, the accused had been acquitted and 34% had been convicted. The main cause of complaint involved treatment and care at 40.1% and 36.6% respectively. In general, the most common causes of complaints were treatment and care for doctors, and lack of respect for nurses and others. Thus, more attention should be paid to the continuous education of medical students and residents during training years in order to increase the knowledge and skills of physicians. Other measures that can reduce complaints are: providing sufficient information to patients before diagnostic or therapeutic procedures improving the equipment in health centers educating the society and raising public awareness of the treatment process offering the necessary information during medical procedures obtaining informed consent careful choice of the medical team and assigning them to the right position and holding communication skills workshops.

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Stressful ethical situations are considered as one of the problems of nursing profession, which disrupts the competence of simultaneous application of knowledge, skills, attitudes, and values in patient care. Since clinical nurses are more exposed to ethical distress due to their nature of job, especially in in critical care and psychiatric wards, this study was conducted to analyze the relationship between three dimensions of moral distress. In this descriptive-correlational study 545 nurses from Tabriz educational centers were selected by census method in 2013-2014. The moral distress scale (MDS) questionnaire was distributed among partcipants and data was collected during nine months. Data were analyzed by SPSS V13, descriptive statistics, Chi-square test, and Kendall's tau-b correlation coefficient. According to the findings, the mean of moral distress was 141.89 ± 29.6 (in the intermediate range). Chi-square test showed the relationship between the dimensions of moral distress (the relation between patient's ignorance, decision-making power, and professional competence) (P <0.05). According to the Kendall's tau-b correlation coefficient test, there was a direct and significant correlation between the dimensions of moral distress (P <0.05). There was a meaningful correlation between the moral distress and the demographic characteristic of the educational level (P <0.05). Considering the direct and meaningful relationship between three dimensions of moral distress (patient's ignorance, decision-making power, and professional competence), each dimension of moral distress affects another as aggravating or modifying factor. Therefore, it is recommended that planners and health care administrators at the macro level provide appropriate programs to increase the nurse's attention and support to patients and reinforce decision-making power and professional competence by increasing the number of nurses and other controlling programs.

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Confidentiality in AIDS patients is one of the necessities of medical ethics, which has attracted the attention of policymakers in the health field in the last few decades because, on the one hand, it increases the trust between patients and doctors. On the other hand, it encourages them to adhere to treatment and do necessary care to patients in order to prevent the transmission of the disease to others. However, it may lead to a breach of benevolence and others’ right to health and cause problems in providing health care.  Here we discuss a practical solution for this problem through a clinical case presentation.

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