Iranian Journal of Medical Ethics and History of Medicine

---

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.

---

Abortion of the disabled fetus is among the challenges of medical ethics, and decision-making in this respect is subject to a major controversy between Islam and Western philosophies. One reason is skepticism about the continued existence and evolution of the human soul after death, which has resulted in legitimacy of abortion of disabled fetuses in the West. Islam and Islamic philosophers, however, attribute great importance to the soul and its evolution, and therefore in decisions related to such embryos all aspects of the body and soul are considered, with more emphasis on the latter. Some issues that are raised in the Islamic worldview include: What is the reason behind embryonic defects? And does a disabled fetus also suffer from a defect in the soul?The present paper is a descriptive-analytical non-systematic review that uses a data collection approach. Regardless of the issue of ensoulment, the study intends to examine the evolution of the spirit (nafs) in the fetus during various stages of life (vegetative, animal and human) based on Mulla Sadra and Imam Khomeini's perspectives. It also aims to conduct a philosophical investigation into defects in creation and to find the answer to the important question of whether the soul of a disabled fetus is also imperfect. Findings of this study show that based on Mulla Sadra’s views, all living things have been created in the best and most perfect form. The disabled fetus is not an exception and therefore has a perfect soul, but the appearance of the soul in a malformed body is defective. The imperfection may have two causes: first, a wrong choice made by the soul of the disabled fetus in the world before this one, i.e. the Zar world, although the concept is among the unfolded mysteries of creation unfathomable by human knowledge second, effect of the genes and/or the environment, regardless of the choice made by the soul of the disabled fetus in the world of Zar.However, since decision making regarding abortion of disabled fetuses is still a matter of controversy in medical ethics, further studies from the perspective of Islamic philosophy seem necessary to help resolve the issue and provide ethical guidelines based on Islamic principles.

---

Social capital and altruism are the most effective factors on the cultural development of a society and can play an important role in promoting ethics within the health care system. The purpose of this study was to investigate the relationship between social capital and altruism and the ethical attitudes of physicians. This correlational and descriptive study was performed on 322 doctors working in medical centers in west Azerbaijan during 2013 who were selected by cluster-random sampling. Onyx and Bullen social capital scale, Carlo et al. altruism scale and Karamporian et al. ethics questionnaire were used to collect data. The results of this study indicated that there was a significant positive relationship between the ethical attitudes of physicians and altruism (R = 0.238), the structure subscale (R = 0.489), cognition subscale (R = 0.581) and relationship subscale (R = 0.554) of social capital. The significance level was set at p < 0.05 in this study. The multi-variable correlation coefficient and enter method indicated that social capital subscales can influence the ethical attitudes of physicians (0.457). The results showed that there was a correlation between social capital and altruism and ethical attitudes in the medical profession. Thus, it seems that promoting social capital and altruism can positively influence individuals’ ethical attitudes in the medical profession.

---

It is universally acknowledged that death is a complex concept and different factors such as complicated philosophical ideas, contradictory descriptive approaches, and diversity in interpretations add to this complexity. Although a thorough understanding of the notion of death is important for everyone, this concept is of crucial importance to health care providers as they face enormous ethical challenges in the course of their careers. A few instances are controversial issues such as brain death, euthanasia and end-of-life care, where it seems essential to define a set of robust criteria for death. On the other hand, it can be argued that death is not a scientific concept and only different branches of medicine can provide a framework to clarify the subject of death. Therefore, it could be argued that theological approaches may shed some light on this concept. In this article, we aim to extract ontologic components of death mentioned in the Holy Quran, and will move on to propose a set of 12 criteria for death. This may help provide a clear understanding of the concept from the point of view of the Holy Quran, although more research is warranted to further illuminate this complex subject.

---

Abortion has remained a subject of intense controversy in medical ethics, particularly in the case of malformed fetuses. Review of the existing literature on the issue indicates that there are two main challenges in this regard: firstly, the question as to whether a malformed fetus has the right to live, and secondly, the fate of the soul (vegetative and animal) after induced abortion.This descriptive research presents different viewpoints in order to investigate the aforementioned questions in Mulla Sadra’s philosophy with a focus on the “right to live”. The results of the study demonstrate that according to Mulla Sadra’s theory, all fetuses possess potential human souls even if they are extremely malformed or disfigured. He considers the fetus a vegetable with the potential to convert into a human. Based on this ideology, which encompasses both creation and resurrection, the malformed fetus has the right to live. The assumption is founded upon Mulla Sadra’s Theory of Substantial Motion, which implies that abortion may influence the evolution of the soul in the limbo period (intermediate state) after abortion and might even affect its resurrection. It can be concluded that in the Iranian society, which has an Islamic background, theological views should be considered in decisions about abortion. It should be mentioned, however, that philosophical approaches alone cannot be relied on for decision-making regarding the abortion of a malformed fetus. Furthermore, interdisciplinary contributions are indispensable to a thorough analysis of this controversial issue so that the ethical challenges surrounding abortion in such cases can be overcome.

---

The precepts of Islamic education are founded on a practical and all-inclusive system that is aimed to develop man in all aspects of his life based on Quranic guidance (Quran and Ravayat). The individual is at the heart of Islamic education, and therefore has a specific place in Islam and is considered sacred and blessed.As a rule, medicine is targeted at the physical wellbeing of man. Consequently, Islamic education can play can play an important role in medical training and may be traced in the Quran and Revayat.Instructors and students are at the core of education and learning, and their development will result in the moral, spiritual and technical advancement of the society. Medical schools aim to cultivate young talents and educate experts in the health industry, and are naturally essential for the development of a nation. This can be achieved through the attempts of capable and motivated instructors within the educational system.The present study is a review of the Islamic approach to medical training and the techniques of developing motivated and capable scholars and students in order to achieve Islamic educational goals.

---

Virtue ethics is an agent-centered approach that is concerned with good and bad character rather than right or wrong action. It is based on the virtues and moral character of the agent. Morality of the physician is emphasized in medicine as well, which demonstrates its affinity with virtue ethics. Nevertheless, a theory of applied or medical ethics should provide a criterion for ethical decision making by instructing what should be done, something which, according to some philosophers, is incompatible with virtue ethics. This article aimed to demonstrate how virtue ethics can offer rules and guidelines by resorting to the moral agent and emphasizing virtues, and help physicians to make decisions when faced with dilemmas. For this purpose, examples about abortion and selling kidneys for transplantation were provided.Some of the most important advantages of virtue ethics include: context-dependence and attention to relevant realities the importance of emotions and the likely motivations of the people involved and finally emphasis on exemplar based on the sensitivity and practical wisdom of the virtuous agent. These advantages cause virtue ethics to be better positioned than other approaches to solving problems in medical ethics.

---

In recent years, the general consensus is that medical education should comprise ethics courses focusing on clinical decision-making skills and professional ethics in order to institutionalize a set of values in physicians. The purpose of this study was to evaluate the internal and external qualities of the medical ethics curriculum from the perspective of students.This was a survey research on a study population of 157 medical students who were taking the medical ethics course. A sample of 113 students were selected by simple random sampling, and data collection tool consisted of two researcher-made questionnaires. In this research, the internal quality of the curriculum was evaluated according to the following 9 elements as proposed by Francis Klein: objectives, content, learning activities, learning strategies, instructional material, resources, grouping, time, location, and evaluation. The external quality of the curriculum was assessed based on Kirkpatrick’s model with attention to students' views on achievement of course objectives in terms of knowledge, skills and attitudes. Data analysis was performed using descriptive statistics (mean and standard deviation) and inferential statistics (one-sample t-test). Based on the findings, the students viewed the internal quality of the medical ethics curriculum as undesirable in terms of the above-mentioned nine elements. Students also believed that the external quality of the ethics curriculum was at an average level in the knowledge and attitudes components, and undesirable in the skills component. Overall, our findings indicate that from the perspective of students, the quality of the medical ethics curriculum is low and the course needs to be reviewed and redesigned.

---

Confidentiality has long been protected in criminal law as an important ethical principle. With regard to the issue of sexually transmitted diseases, however, health care providers are faced with certain challenges. On the one hand, it is their obligation and duty to respect patient confidentiality, and on the other hand, the possibility of transmission of infection to sexual partners is a rather significant phenomenon. Therefore, health care providers have a crucial role in terms of the conflict of interests and legal duties with respect to sexually transmitted diseases.Medical mandatory reporting to state authorities accompanied by personally identifiable information of the infected person is another controversial issue in the field of confidentiality, which will be discussed in this article by studying various trends in statutes and precedents. It seems that throughout the world, there are two major trends in this respect: in some states, principles of confidentiality are observed even if the patient is infected by sexually transmitted diseases, unless it is inevitable for the safety of third parties such as sexual partners in a narrow implementation of Acts. States like Iran, France and Thailand are examples of such governments. In some countries, however, partner notification and compulsory notification by personally identifiable information of patients are mandatory for epidemiologic reasons. The United States, Australia and Ukraine are some of the countries that fall within this category. In Iranian legal system, the duty to respect confidentiality is emphasized and partner notification cannot be considered as a legal duty and therefore it is not legally permitted. Merely in emergency condition and under a narrow interpretation of law and by resort to patients informed consent, necessity and explicit law permission, breaching of confidentiality is justified.

---

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.

---

Emphasis on the organizational commitment of employees is a soft management technique to enhance performance and efficiency. This study aimed to determine the relationship between organizational commitment in the employees of Tehran University of Medical Sciences (TUMS) and their tendency to display non-ethical behavior.

This study was a descriptive analytical and cross-sectional research conducted on the headquarters employees of Tehran University of Medical Sciences during 2013 and 2014. A sample size of 150 employees was determined using the Cochran formula. Research tools consisted of a researcher-made questionnaire measuring non-ethical behavior, and Allen & Meyer’s Organizational Commitment Scale. The validity and reliability of both questionnaires were confirmed. The response rate was 85%. Data were collected using the SPSS software, and Pearson’s statistical methods were applied.

The average organizational commitment of the employees in this study was 62.32, which is considered as moderate. It should be added that the majority of the employees did not demonstrate a tendency for non-ethical behavior.

Although the average organizational commitment was not high in TUMS employees, it was not correlated to their non-ethical behavior tendency. It seems that the organizational commitment of TUMS employees is influenced by other factors such as supervisor and organizational ethics, which can be the subject of future studies.

---

Severe combined immunodeficiency (SCID) is an inherited primary immunodeficiency syndrome characterized by a profound deficiency in T-lymphocytes and variable defects in the B-lymphocyte number. The present study aimed to evaluate the ethical aspects of the clinical management of children with SCID. This report is based on the case of a 6-month-old male infant with SCID diagnosis presented during the Medical Ethics Grand Rounds in the Children's Medical Center in Tehran, Iran.

The patient had a positive history of recurrent infections and frequent hospitalization. His parents were consanguineous and came from a low socioeconomic level of the community. He was the fourth child of the family. The first and second children were healthy girls, while the third child was a boy with a history of numerous problems post vaccination who had eventually died of widespread infections. The physician had recommended bone marrow transplant, but the parents had been directed by a neighbor to visit a religious healer.

Timely management of severe combined immunodeficiency can reduce complications and improve the patients’ quality of life. The need for early screening tests is therefore ethically justified, although ethical issues surrounding the subject should not be overlooked. Instances of these issues include: neglecting the scientific criteria necessary to conduct the tests the economic burden imposed on the family of the child failure to provide sufficient information to parents and ignoring their consent to conduct testing and treatment lack of equitable access to diagnostic and treatment facilities and lack of attention to the child’s autonomy. It should, however, be noted that in certain cases, healthcare providers could perform their management activities with an ethical and supportive approach, taking into account all physical and psychological needs of infants with severe combined immunodeficiency, as well as those of their families

---

Women are the epitome of affection and are therefore suited for the caregiver role by nature. In Prophet Muhammad’s era, women entered one of the toughest and perhaps most masculine areas of social life, that is, the battlefield. Prophet Muhammad permitted and endorsed the presence of women in battles, and appointed troops of women to accompany him to war for the purpose of providing nursing and medical care. The importance of this issue lies in recognition of the role of Muslim women in social arenas such as battlefields. This study aims to: a) investigate the medical role and performance of women during wartime in Prophet Muhammad’s era, and b) describe the medical function of women in the Prophet’s battles while introducing some who have been active in this domain.

This was an analytic/descriptive study conducted by collecting note cards from library resources. Our findings showed that women had a significant presence in battles during the early stages of Islam, and as historical evidence confirms, they appeared in the caregiver role by the permission of Prophet Muhammad. Moreover, women’s presence was not due to a shortage of men in the battlefield, but rather because of their abilities in the field of medicine and healthcare, where they succeeded in offering a remarkable performance.

---

Cryopreserved embryos are considered as abandoned embryos in two situations. The first situation is when the embryo`s owners have no definite domicile and no written guideline has been provided by the couple regarding the embryo`s status. The second one is when the owners of cryopreserved embryos explicitly state that they permit the freezing centers to decide about their embryos` fate. The aim of the present study was to determine the best possible decisions about cryopreserved embryos in case of their abandonment by couples.

This research was conducted through library and analytical research methods.

As the cryopreservation of embryos is expensive, cryopreservation centers must be exempted from preserving embryos after unsuccessful attempts at communication with the owners and passing of reasonable time.

Making decisions about the fate of abandoned cryopreserved embryos depends on the nature we attribute to them. If we consider abandoned cryopreserved embryos as humans, it is possible to destroy them according to the rule that necessities allow prohibitions. If we consider them as properties or quasi-properties, when there is no accessibility to their owners in order to determine their fate as properties, the governor is permitted to make decisions about their disposal or donation for researches.

---

Despite all recent advancements in medical sciences and the related technologies, the concept of death still remains obscure. It can be asserted that as death includes both physical and spiritual dimensions, medicine alone is not capable of fully illuminating its different features. Therefore, inter-disciplinary collaboration between different branches of science such as Quranic studies, humanities, and philosophy seems necessary in order to shed some light on this hitherto undiscovered subject. Through description of what the soul experiences before and during death, such collaborations may even enrich the knowledge and broaden the minds of physicians who are capable of the analysis of physical changes caused by death. This insight can promote the ethical decision-making process as well as the provision of end-of-life care and spiritual support in different stages of death. The current research, as a library literature review, endeavors to provide a descriptive view of death from a medical perspective, and then, a Quranic depiction of its different stages through an analysis of verses and quotations from the holy Quran and Islamic scriptures whose primary focus is the process of dying. The final discussion section presents some similarities and differences observed between viewpoints and raises questions which can be considered as being of great practical importance in terms of provision of necessary end-of-life spiritual support. We hope that further research in this field can better clarify the issues raised in this article so that practical measures aiming at the provision of Quran-based spiritual end-of-life care are designed and implemented.

---

Traditional and complementary medicine centers, as providers of health services, have a special responsibility towards patients and clients. With increase in the number of these centers, the role of traditional and complementary medicine has become more important in the analysis, diagnosis, and treatment of illnesses. The accurate and fast performance of medical approaches using evidence-based diagnostic and therapeutic procedures, with consideration of the rights, integrity, and dignity of clients are among the priorities and necessities that can have a significant impact on the satisfaction and acceptance of the scientific and legal institutions, parallel to the deployment of new services provision systems. Lack of sufficient scientific evidence of efficiency and effectiveness, lack of definition and determination of authorities to handle complaints, the legal process of ethical and legal aspects of medical errors has caused challenges for the field of complementary and alternative medicine. Thus, this legal void must be filled through formulation and revision of laws and regulations, defining of the practical and acceptable set of scientific resources, and determination of authorized service centers to resolve complaints and to punish. It is hoped that the results of this review study increase the information of the professionals in this field and attract the attention of authorities of medical ethics to this field.

---

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.

---

Errors in health care services may cause irreversible harm in some cases. Medical errors are a threat to the welfare and health of the patient and their family and should be prevented. The majority of medical errors have little impact on human health, but some of them cause huge losses. This report describes a case of laboratory error in amniocentesis during pregnancy in which uncertain test result caused anxiety and lots of concern for the family. Inappropriate approach to medical error causes more errors to happen. Studies have shown that appropriate reporting and shift from traditional to systematic approach are important factors in reducing the frequency of medical errors.

---

Archaeological evidence and various historical documents indicate that Chinese were aware of the lands beyond the mountains of the West, especially Iran. This article argues that Iranians had a great role in transferring Iranian religions as well as some other religions such as Christianity to China. As such, the transfer of medical knowledge had had occurred along with transferring those religions and beliefs.

As it is the case now, in the past, business relationship between countries and different ethnic groups played a great role in knowledge transfer between nations. By reviewing the existing historical documents, library resources and archaeological findings, show that the extensive trade exchanges between Iran and China, lead to not only cultural exchange and religious beliefs but also the transfer of medical beliefs, knowledge and practices to China. This happened by the Iranian religious envoys as well as non-Iranian religious missionaries. In conclusion, this knowledge and technology transfer had an impact on the flourishing Chinese medicine.

---

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.