Iranian Journal of Medical Ethics and History of Medicine

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

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

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

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

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Confidentiality is an inevitable pillar of the history of the physician-patient relationship. Misunderstanding of this principle not only causes harm to sanctity of the medical profession, but also can damage the quality of the therapeutic relationship, and more broadly public health. The keystone of this negative effect is the potential harm to the patients’ trust and confidence. Generally, the Western school tends to agree that respecting patient confidentiality is essentially desirable. Islam also respects and emphasizes confidentiality, and has general and some specific recommendations about the importance of secrecy and concealment of people’s secrets. Overall, despite strong agreement about the importance of the principle, some ethical theories do not insist on maintaining confidentiality under any circumstance. This paper is an attempt to describe the importance of confidentiality in the medical profession considering the approach of both absolutists and relativists in practice.Absolutists believe that the intrinsic desirability of implementing the principle of confidentiality in all cases is the same and without any exception, but the issue is about not giving just priority to other conflicting moral values.Additionally, the absolutists believe that breaching this principle in practice cannot be permissible due to some serious long-term and mostly hidden complications such as patients’ failure or delay to seek medical assistance or advice and/or withholding important information and so forth. Overall, according to empirical evidence and rational considerations, adherence to absolute confidentiality seems more desirable to absolutists. Unlike absolutists, in relativists’ concept of confidentiality, insisting on maintaining the secret will not be allowed in certain cases, and those cases are considered exceptions of the rule of confidentiality.The most important reasons for falling into the wrong orientation of relative confidentiality seem to be precipitance to attain the desired result, poor communication skills, ignorance of the consequences, and being headstrong.

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Breaking bad news is one of the most difficult tasks an emergency physician has to perform and unfortunately it is not well studied. Almost all of the original studies for compilation of the guidelines of breaking bad news have been conducted in a non-emergent situation and were physician-oriented. In this study and by reviewing related articles in medical databases, the authors try to show the necessity of adapting these guidelines into the situation of the emergency departments and indigenizing them for non-Western countries. This can be the first step to design a guideline for the emergency department.The different nature of bad news and the chaotic situation in the emergency departments are the two most important points that may prevent using these guidelines in the emergency departments. On the other hand, breaking bad news guidelines are designed based on Western cultures and their application in a non-Western country may decrease their effectiveness.To the best of our knowledge, there is no national guideline for breaking bad news in Iran. There is a long way to go before we can suggest a national guideline for emergency departments, so we recommend using one of the Western guidelines and indigenizing it according to the Iranian culture and emergency situations.

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Ali Afzal Ghate’ Ghazvini was a renowned physician, scholar, and calligrapher of the Safavid era whose personality and efforts in the field of medicine have not been fully recognized thus far. Among his works, three medical treatises can be of use in researching the medicine of the Safavid era. The present article adopts a descriptive-analytic method to introduce one of these treatises, Favaed-al-Afzalieh, and present a survey of its content in addition to the author’s biography. The findings here are based on the three chapters of this medical classic, which indicates the encyclopedic nature of this treatise. Favaed-al-Afzalieh reveals details on a variety of practical medical issues prevalent in the Safavid era, and is considered outstanding due to the volume of all the medical information it contains. The present study discusses the standing of this treatise in the history of medicine along with a suggestion to revise and publish this valuable, comprehensive work and reintroduce it to the world of medicine.

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Fertility preservation consists of a set of procedures that help people maintain their reproductive ability in order to have a genetic child in the future. Nowadays, these procedures are widely accepted as long as they fall within the two categories of medical or social justification. In the first category, patients may lose their fertility due to diseases or treatment-related complications, while, in the second, healthy patients wish to preserve their ability to have children in the future for social and personal reasons. Since these procedures are considered invasive, many questions and criticisms have been raised about their application in the case of healthy women who seek them merely on account of aging.In this descriptive-analytic study, ethical issues were retrieved from books, papers, international guidelines, theses, declarations and instructions, and even some weekly journals, using keywords related to fertility preservation such as embryo cryopreservation, oocyte cryopreservation, and women’s reproductive autonomy. In cases of medical necessities, fertility preservation is considered acceptable and consistent with the principle of beneficence, which is the most important principle of medical ethics. As for cases that only have social justifications, some argue that they contradict the principle of non-maleficence. Nevertheless, a large number of feminists and scholars believe in women’s reproductive autonomy and therefore consider them ethical, provided that certain conditions are observed.

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It has been over five decades since the concept of “spiritual health” was first introduced in academic texts, and although many studies have been conducted on the subject, there exists no consensus on its definition and components yet. Nonetheless, this concept has been an inextricable part of Islamic Theology, which is more than several hundred years old. Therefore, it can be asserted that observation and analysis of the lifestyles of Muslim scholars may shed some light on this seemingly complex concept. This analytic-descriptive article was designed to provide a straightforward definition for spiritual health and explore its different components from the viewpoint of Ayatollah Hassanzadeh Amoli, a renowned Shiite scholar. In this article, spiritual health refers to the health of the soul and is related to both material soul and the body itself. The Ayatollah puts special emphasis on the importance of living a healthy lifestyle and on the health of the material soul in order to promote spiritual health. In this article, we endeavor to conduct a thorough analysis of the lifestyle and views of Ayatollah Hassanzadeh Amoli.

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Recent provisions to the Islamic Penal Code have provided favorable regulations that absolve the skilled physician from absolute liability and adjust liability according to fault. The revised code adopts a new approach by allowing physicians more freedom while providing added protection, which is consistent with ethical standards and Jurisprudential principles. The present paper aimed to investigate the development process of statutory laws in Iran regarding medical liability and at the same time analyze articles of the Islamic Penal Code of 2013 on the subject. Some articles have been found to contain ambiguities that need to be modified. As an instance there seems to be a conflict between Article 492 and Clause 1 of Article 496 that should be resolved as it pertains to a case of the cause and the perpetrator (physician and nurse). In these situations the doctor orders and the nurse acts, and it is therefore necessary and proper that physicians not be absolved from liability.

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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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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.

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A model is a summarized representation of facts. Health-related models show values, perceptions and various understandings of health care. This study investigated the nursing advocacy models and the nurses’ protective role. In this review article, related literature and documents were searched in PubMed, Science Direct, Proquest, Google Scholar, Magiran, Iran Medex, and Scientific Information Database, using the general search engine Google. The search was performed by keywords “advocacy” and “nursing advocacy model”. In this stage, 89 sources including books, articles and dissertations on the subject of nursing advocacy written between 1991 and 2014 were collected. In the next stage, 43 sources were chosen for the review article. Finally, 8 models that were more consistent with the topic and objectives of the study were extracted. Considering the findings of this study and the benefits of nursing advocacy, we propose to design a model in order to promote the advocacy role of nurses in Iran. In this model, legal constraints, social factors and values, organizational culture, position of the nurse in the health care system and political‌ and economic considerations should be taken into account.

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Nowadays academic life is closely related to the issue of publication. Consequently, there are numerous challenges in naming authors of scientific papers and publication ethics in general, making it essential to identify the various problems in this area. The present article acquires a historical view to investigate the challenges and solutions related to this topic.This is a review article based on a search of scientific databases from 1985 to 2014. Honorary authorship, coercion authorship, ghost authorship and non-compliance are instances of ethical issues in naming authors. To solve these problems, several agencies have provided ethical guidelines in this respect including the International Council of Medical Journals Editors (ICMJE), contributorship, objective measurement tools and the National Directory of Ethics in Medical Research Publications. Nevertheless, studies point to the existence of problems in this area.In order to solve the existing issues, the evaluation system of scientific and research organizations should propel quantity-oriented evaluation over quality oriented criteria. We also believe that the educational system, specifically in the post graduate period, can affect scientific research and publication ethics to a great extent and thus promote ethical conduct in students and researchers.

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In recent decades, advancements in genetics and medical technologies have made it possible for clinicians to diagnose and sometimes treat fetal abnormalities in early gestational stages. This issue presents numerous ethical challenges for parents, doctors, ethicists, jurists and other professionals in terms of the continuation or termination of such pregnancies. A non-systematic review was performed to extract the main ethical codes that should be considered when offering counseling to pregnant mothers of fetuses with congenital anomalies. Moreover, since the attitude toward the status of such fetuses in the world of creation can strongly affect ethical decision-making, we attempted to investigate the issue further by offering some Islamic perspectives on the subject.Considering Islamic principles in offering ethical advice to Muslim parents of fetuses with congenital anomalies will help them make an informed and more appropriate decision in serenity. We hope the results of this study will facilitate ethical decision-making in health care and related disciplines, and thus help us deal properly with the issue of disabled fetuses.For future studies, it is recommended to compile related ethical guidelines based on Islamic principles to investigate various aspects of the issue.

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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.

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Medical futility refers to diagnostic, treatment, and rehabilitation interventions that are unlikely to produce any positive outcome for patients. Doctors should beware of such actions due to their professional commitments. There are ambiguities in the definition of futility that have been the subject of many studies. In this paper, relevant literature was reviewed to find a definition for futility from the perspective of the four bioethical principles.Determining the futility of an action, whether it is the request of the patient, their family or service providers, is a highly sensitive matter that can lead to unethical decisions in the medical profession.Autonomy is a concept that is related to the diverse views on treatment objectives. In this paper we investigated the issues of physician and patient autonomy, and the differences between the values of the people involved. We have also discussed the concept of palliative care with an attempt to clarify the difference between this type of care and futile care, and to determine the boundaries. Another focus of our study was situations where physicians and other health care providers deliver futile treatment for various purposes. Such cases involve factors that may influence the judgment of physicians, and some of them are unethical due to incentives such as financial gain.Finally, ethical decision-making in this area is only possible through clarification of the different aspects of the issue and prioritization by experts and professionals. In order to do so, all circumstances need to be taken into account, including allocation of scarce resources within the health care system and fairness. Moreover, medical staff should have access to the necessary information so that they can make ethical decisions in different situations.

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The principal objective of the nursing profession is to provide evidence-based and competent care mainly based on humanitarian and ethical principles. Ethical care is contingent on a proper level of moral reasoning, which can be categorized into pre-conventional, conventional and post-conventional reasoning. At the pre-conventional level, individuals are mostly self-oriented and prefer obedience to avoid blame. At the conventional level people apply laws and social principles to decision-making, and at the post-conventional level they try to guide their actions and behaviors with regard to ethical principles and make humanist and ethical decisions. This study aimed to assess the level of moral reasoning in nurses and nursing students by providing an analysis of the existing literature on moral reasoning.For the purpose of this study, we conducted an extensive search of the papers published between 1980 and 2014 on international electronic databases including Scopus, Google scholar, Science Direct, PubMed, Proqust and Elsevier. We also reviewed papers published between 1985 and the autumn of 2014 on Persian electronic databases Sid, Magiran and Iran Medex. A broad range of search keywords were used such as: ethical growth, moral growth, ethical development, moral development, ethical reasoning, moral reasoning, nurse, and nursing student. In total, 35 studies were reviewed at this stage.Based on the results of the above-mentioned studies, most nursing students and nurses reason at the conventional and post-conventional level, and nursing students reason at a higher ethical level in comparison with nurses. We also found that teaching ethical concepts helps improve ethical reasoning, and that an inverse relationship exists between clinical experiences and ethical reasoning.Although in most studies, the level of moral reasoning in nursing students and nurses was found to be at the conventional and post-conventional level, this is not enough to provide superior professional care. It is therefore essential to apply the necessary measures such as improving clinical environments and the ethical education system to further promote the reasoning ability of nurses and nursing students, so that they can make their decisions based on ethical principles and at the post-conventional level