Iranian Journal of Medical Ethics and History of Medicine

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In order to achieve teamwork-based and integrated care, one of the issues in health care is the implementation of ethics and values in teamwork. The aim of this study is to develop the interprofessional collaborative ethics framework.This cross sectional study was conducted in two phases. In phase one, core competencies of the interprofessional collaborative ethics were determined by literature review. In phase two, Delphi rounds of experts were undertaken to validate the competencies and calculate content validity indexes through Content Validity Ratio (CVR) and Content Validity Index (CVI).The interviews and Delphi rounds identified 12 competencies categorized in three core themes including patient-centered values, interprofessional collaborative ethics, and team-based values. In phase two, based on the mean scores of importance, utility, and clarity, patient center value (4.9), interprofessional ethics competencies (4.6), and team-based values (4.5) were determined as essential themes.In conclusion, the validation of the inter-professional ethics framework was found to be acceptable in the Iranian context. Therefore, the framework for teaching and evaluating inter-professional ethical competencies is an applicable tool in the Iranian context.

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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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Breaking bad news emotionally affects both health professionals and patients. Breaking bad news is a sensitive issue for both health care providers and patients. It is generally believed that the patient’s adjustment can be affected by either a positive or a negative experience in this respect. This study aims to determine health care providers’ attitudes toward breaking bad news to parents in NICU and labor wards.This cross-sectional study was conducted in Shahrecord in 2011 with a study sample of 70 health care providers drawn from neonatal intensive care units and labor wards and the department of nursing and midwifery who had had at least one year’s clinical experience. The sampling method was census. Data were collected through a self-administered questionnaire in two sections: demographic information and health care providers’ attitudes toward breaking bad news. Data were analyzed by SPSS software with descriptive and Chi-square and T-student test statistics. Most participants (63.2%) had a positive attitude toward disclosing bad news to parents. 77.6% of caregivers faced difficulties in delivering bad news to parents, 92.6% of them believed that training workshops in this field are necessary. There was a significant statistical relationship between the attitudes of the health care providers and their education level and work place (P < 0.0001). Health professionals with higher education levels and nursing and midwifery staff had more positive attitudes.There was no significant statistical relationship between the attitudes of the health care providers and their history of difficulties in transferring bad news, workshop trainings, work experience, gender, age and marital status (P > 0.05). The majority of health professionals had a negative attitude toward immediate disclosure of bad news to parents, mothers holding and seeing their deceased babies, dedicating a special room to perinatal loss mothers with similar problems, and preventing other patients and their families from contacting them.Based on the findings of this study, teaching bad news communication skills to personnel of NICU and labor wards should receive prioritization in future continuing medical education programs in order to best prepare the staff for disclosure of bad news to parents.

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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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Medical laboratory services and its clients are somehow different from services of the other sectors in the health system. Patient’s Rights Charter, published by the Ministry of Health and Medical Education, was comprehensive, but addressing specific aspects of the related areas in medical laboratories could promote the commitment and dedication in laboratory professional services hence, development of the Patient’s Rights Charter in medical diagnostic laboratories was put on the agenda. After a comprehensive review of existing references and resources, a committee was formed consisting of representatives of laboratory associations and experts in this field, and the draft was prepared. Thereafter several meetings and workshops were held and the members of legal organizations, medical ethics experts as well as laboratory stakeholders, technical staff and laboratory directors attended these gatherings where the draft was surveyed and comments were received. The draft underwent some changes and was edited. Finally in August 2012, the charter was approved by the Health Policy Council of the ministry and in October 2012 was officially announced by the health minister.To be consistent with the context of the Patient’s Rights Charter, essentials of this bill have been based on 5 pillars: access to appropriate laboratory services, access to information in a sufficient and effective manner, the right to choose and decide freely, respect for customer privacy and the principles of confidentiality and integrity, and availability of an efficient system for investigating complaints and suggestions.Developing and delivering the bill of rights for health services recipients is one of the foremost matters, but implementation of the provisions of the charter and monitoring of its effectiveness are the most important goals ahead. Therefore, an effective strategy to implement the rights of patients in medical laboratories should be designed and established.

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Heart failure not only affacts the patients but also their families and social networks. This study was conducted to evaluate the development & psychometric properties of the Social Dignity Questionnaire (SDQ) in heart failure patients. This study is an exploratory research of questionnaire design type. Twenty two patients with class II to IV heart failure (New York Heart Association Functional Classification) were chosen through purposive sampling from selected hospitals of Tehran, and semi-structured interviews were conducted with them. Qualitative content analysis was performed to analyze the interviews. The primary items were developed based on the findings obtained from the interviews, literature and designed questionnaires about social dignity. Content validity and construct validity were determined in 130 patients with heart failure. The data were analyzed using SPSS version 19. Through face validity and content validity analysis, 16 out of 101 primary items were removed. As a result of exploratory factor analysis, 2 items with factor loading less than 0.5 were deleted, and 6 were removed due to inclusion in other factors. The following five factors were extracted: family communication and support, social communication and support, health care communication and support, burden to others (physical, emotional and social), and burden to others (economic). Reliability of the Social Dignity Questionnaire (SDQ) was calculated to be 0.97 by using Cronbach’s alpha coefficient, and 0.99 by using split-half method.Considering the acceptable validity and reliability of the questionnaire in the present study, its application can be useful in planning support for patients and improving their treatment and care. The questionnaire may also be helpful in conducting further research related to dignity in different patients

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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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Secrecy or confidentiality has always been considered a crucial issue in the medical profession. Secrecy is a common and essential principle among patients and physicians, and is highly emphasized in professional ethical codes and guidelines.This case report is based on an actual case in Medical Ethics Grand Rounds in Tehran Children's Medical Center, with a glance at the boundaries and challenges of keeping and revealing the secrets of the patients.Case Scenario: In this report, a neonate with withdrawal symptoms was admitted to the hospital. After routine examinations by the medical team, they found the neonate’s mother was addicted and had concealed her addiction from her husband and her family. To facilitate treatment of the infant, they discussed the matter with the mother in order to get accurate information. The mother’s denial on one hand, and the need for accurate and comprehensive information necessary to begin treatment on the other caused a challenge to keeping or disclosing the mother’s secret. Here the medical team assumes responsibility to obtain the information from the mother, convince her and win her cooperation, and finally share the secret with the spouse to help their ill neonate.Although respect for patients’ confidentiality is an imperative issue for physicians and healthcare workers, it is not an unequivocal requirement. Due to logical and religious reasons and based on each specific case, it is necessary to make decisions that are more reasonable and less harmful to the patients and their families. Naturally the staff is required to keep the secrets of their patients permanently.

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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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Holistic care is a comprehensive approach for achieving optimal level of care for patients. Identifying the motivational factors can increase quality of nursing care and improve the healing process. Investigation of nurses’ experiences will provide real and meaningful results in this field. In this study we aimed to explore nurses' experiences regarding holistic care.This qualitative study was conducted on 18 nurses from Uremia, Tabriz, Ardebil and Tehran teaching hospitals of Iran. The data were obtained by interviews with nurses. These interviews were transcribed and analyzed by the conventional content analysis method and using MAXQDA software.Personal characters and experience of hospitalization were identified as motivational and promotional factors in providing holistic care.Considering the role of personal characters and experience of hospitalization in holistic care, paying more attention to nurses’ characteristics and upgrading their communication skills and knowledge are necessary for development of holistic care and are highly recommended.

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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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Considering the advances in today's world, the increased complexity of diseases and longer life expectancy, nurses experience a great deal of moral distress. One factor that is likely to contribute to the development of moral distress is the ethical climate prevailing in hospitals. This study aimed to assess the relationship between nurses' perceptions of moral distress and the ethical climate in Shahid Sadoughi University of Medical Sciences in Yazd. This correlational descriptive study used the Moral Distress Scale (MDS) and Hospital Ethical Climate Survey (HECS) to examine 370 nurses working in a number of hospitals including Shahid Sadooghi, Shahid Rahnemun, Shahid Afshar and Savaneh Sukhteghi. Data analysis was performed using SPSS18 and descriptive and analytical statistics. Findings showed that the intensity of perceived moral distress among nurses was 3.41±1.28, and their perceptions of the ethical climate were 3.22±0.78. There was a significant negative relationship between nurses’ perception of moral distress and the ethical climate (P=0.00). The findings of this study suggest that development of plans to improve the ethical climate prevailing in hospitals might decreases nurses’ perceived moral distress.

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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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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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In the nursing profession, moral distress is a challenge thatc an have different consequences. The nurses’ moral courage to make the right decision can play an important role in the prevention of moral distress, and thus promote moral comfort. The present study examined the relationship between moral distress and moral courage in nurses. In this study, 313 nurses from hospitals in southern Khorasan Province were selected through quota sampling, and Corley’s Moral Distress Scale and the Professional Moral Courage Scale by Sekerka, et al. were used for data collection. The collected data were analyzed by descriptive and analytical statistics. The findings showed a significant relationship between the intensity of moral distress and moral courage (P = 0.03, r = - 0.44). From a range of 0 - 5, the mean of moral distress was 3.7 ± 0.5 in terms of intensity, and 3.55 ± 0.86 in terms of frequency. The mean score of moral courage was calculated at 3.33 ± 0.46 from a range of 1 - 5.The significant correlation between moral distress and moral courage strongly suggests that high levels of moral courage in nurses can play an important role in controlling moral distress. Determining the factors that create moral courage and developing strategies and circumstances such as promoting an appropriate moral climate could play a major role in encouraging moral behavior and controlling moral distress.

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The nursing profession is based on ethics. Clinical decisions that most nurses have to deal with include cases that involve moral conflicts. Moral distress is a phenomenon that causes pain, suffering, anxiety, depression and psychological damage. Emotional exhaustion can cause moral distress and is a consequence of job stress that has even been investigated as a reason for the high turnover in nursing. Therefore, the present study investigated the relationship between moral distress and emotional exhaustion among nurses.In this cross-sectional study, 265 nurses who employed in teaching hospitals of Sabzevar University of Medical Sciences were selected through convenience sampling. Data collection tools included a questionnaire on personal information a moral distress scale whose validity and reliability had been measured in previous studies (Cronbach's alpha 0.86) and a scale for emotional exhaustion that had also been tested for validity and reliability through content validity and test-retest (r = 0.84). Data analysis was performed using SPSS version 18.In this study, mean and standard deviation of moral distress and emotional exhaustion of nurses were 4.99 (0.91) and 4.17 (1.58) respectively. A statistically significant correlation was found between moral distress and the nurses’ field of work (rho = 0.338, P = 0.000). There was also a significant correlation between emotional exhaustion and rotating working shifts (rho = 0.385, P = 0.000) and ward (rho = 0.173, P = 0.03).The moral distress and emotional exhaustion of the nurses in this study were found to be higher than average. Education, counseling and raising nurses’ awareness of these concepts seem to be necessary in order to empower them to better deal with ethical issues.