Iranian Journal of Medical Ethics and History of Medicine

---

---

Brain death is a subject in our society which can be mistaken with coma or other types of life status similar to death. To assess the legal status of a brain dead patient, it is necessary to determine whether a person afflicted with brain death is dead or alive. Do they meet the criteria for biological death? Or in precise words, do Islamic laws for the dead apply to them? Several questions arise in this regard, which give more importance to this issue from the viewpoint of Islamic jurisprudence and law, and all answers depend on our definition of brain death, and whether we find brain death an instance of the separation of body from soul. There has been much research around this issue and the laws in many countries and religions, including Christianity and Judaism, have been disambiguated. In Iran, however, brain dead patients are considered alive, while brain death should be legally considered absolute death like in many medically advanced countries (UK, Germany, France, and USA). The authors aim at examining this issue from the viewpoint of Fiqh and law, and its disambiguation.

---

In the past generations and throughout the history of dentistry, horrific and deadly epidemics of the diseases transmitted through blood have not been a concern for those in the dental care profession. This has been due to the success of this profession in maintaining the oral health of patients. Questions such as whether dental treatments can potentially spread HIV and AIDS have therefore not been discussed extensively, and there seems to be a shortage of reference for dentists to find comprehensive and accurate answers to these questions. As a matter of fact, several generations of dentists, and health care providers in general, have continued to perform their duties despite the possibility that they could be exposing their patients to a deadly infection, and have not even apprehended a fatal pandemic. Consequently, it is not surprising that the professional norms that today’s dentists were educated on during their training years should fail to give clear answers to their questions regarding AIDS and HIV nowadays. The present paper will cover this issue in connection to HIV positive patients from the ethical and professional point of view.

---

Evaluation of the factors related to the patients&apos complaints against medical staff, especially doctors and efforts towards its reduction affects patients&apos satisfaction of health care system.  The main purpose of the present study was to determine the factors related to the patient`s complaint against doctors with the verdict of Medical Council of Kerman.
This study was a descriptive, analytical and practical evaluation, assessing 250 documents related to the patients&apos complaints of doctors in Kerman Medical Council during 2004-2009.
 The most reasons of complaints (%73.2) were carelessness and disrespecting scientific and legal standards, and obtaining funds out of legal standards (%9.3) respectively. In the case of issuing vote, the most opinions (%31.7) were innocence and suspended and barred from prosecuting (%22.9) respectively. Most complaints were of ophthalmologists and private hospitals.  There were significant relationship between the reason of complaint and issued out (P<0.01, c²= 53.706) and the reason of complaints and field practitioners (P=0.026, c²= 49.27). No significant relationship between issued out and the type of hospital was found.
Regarding the results, respecting scientific, and legal standards, and decreasing financial relationships between doctors and patients is an effective way in reducing patients&apos complaints of physicians. Improvement in physicians&apos patients&apos relationship by explaining the disease condition, its risks and treatment options to patients are effective in reducing patient&aposs complaint against physicians.

---

The aim of this study was to explore experiences of family members of patients confronting brain death diagnosis and the request for organ donation.
A qualitative study was designed focusing on content analysis. Data collection process included 38 unstructured in- depth interviews with relatives of 26 brain death patients who were candidate for organ donation and field notes. Sampling method began as purposive and continued as theoretical until saturation.
Five main themes were extracted from the current dataset that indicated family experiences and perceptions of brain death concept while being informed. The themes were included internal conflict, internal barriers against external realities, imminent sense of loss and grief, surrender and acceptance.
The results showed that facing the diagnosis of brain death for relatives and family members is a condition surrounded by many challenges, ambiguities and conflicts that is become more complicated when emotional responses related to grieving and defensive psychological reactions emerge. So it is recommended before any organ request, at first medical team provide conditions for brain death acceptance. Respecting family members experiences and their perceptions about the situation will resolve their internal ambiguities and conflicts. At this situation requesting organ donation seems to be rational.

---

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.

---

In medical etiquette and ethics, benefit and harm assessment includes risk evaluation, rational risk, distinction between medical and non medical utilitarian considerations, individual and community benefit ratio, and issues of the like. This article explores philosophical foundations of this issue. In philosophy, benefit/harm reduces to pleasure/pain and good/bad. Pleasure (spiritual and non-spiritual) is considered a subjective criterion for benefit, whereas applied ethics needs an objective criterion. To achieve such a criterion, we need a specific model for casuistry evaluation and a holistic and organic approach. This article advocates the public sphere model and presumes it is the missing link of ethical confusions and the solution to ethics lack of quantifiability. Public sphere sits between public authority and private sphere, and supervises them impartially. Benefit/harm evaluation components in medical research requires such sphere for clarity and distinction.

---

---

Though there are different definitions for the word “mawt” (death), it seems that the most appropriate one would be the loss of power of the soul over the body, and that is when the soul is separated from the body. There are a variety of religious rulings for a human’s death in Islamic moral jurisprudence, and therefore it is necessary for a jurisprudent to have proper knowledge of the subject, reality, and the criterion for death and life. There are two main theories on the criterion for death and life from jurisprudential and moral perspectives. Some hold that everyone dies of cardiac arrest and others argue that man dies of brain death. It is also necessary to view the arguments presented by each group from jurisprudential and moral perspectives. Advocates of the theory of cardiac arrest support their view through the following reasons: authority of established practice in concept analysis, incumbency of guarding the protected soul, principle of caution regarding people’s lives, and principle of istishab. Authors of the present paper have attempted to provide a critical analysis of the above-mentioned arguments in this study. Advocates of the theory of brain death hold their view through the following reasons: the fetal heartbeat before the soul is breathed into it, possibility of cardiac transplantation and impossibility of brain transplantation, similarity between death and sleep, and signs and symptoms of death, among which two have been accepted: a) possibility of cardiac transplantation and impossibility of brain transplantation and b) signs and symptoms of death.

---

Professionals who provide assisted reproductive technology (ART) services may be approached by patients who have no chance of success of treatment, or can even be harmed during the requested futile treatment. In such cases, what is the moral duty of those who provide treatment services, in particular the physicians? Does the mere request on the part of the patient free the doctor from his/her professional moral responsibilities? On the one hand, principles of individual autonomy and beneficence require the doctor to provide the patient with necessary treatments regardless of the results and consequences. On the other hand, the principle of non-maleficence requires the physician not to impose any harm on the patient. In addition, due to the limitation of resources, doctors are obliged to allocate them to those patients who have a better chance of recovery and use them in cases in which the probability of resource waste is low. However, does this sit well with the principle of justice, especially where the patient is willing to pay all the costs of his/her treatment? Whose interest does the doctor have to prioritize, the patient’s, that of the child resulting from ART, or the society’s? Given the above points, moral training of the team providing treatment services seems necessary so that they acquire the essential skills to make the right decisions in difficult situations such as those mentioned above.

---

More than half a century has passed since the onset of successful life-saving and at times astonishing transplantations of organs from brain dead donors, numerous books and articles have been written on the subject, and local, regional and international meetings and conferences have been held. Nevertheless, no consensus has yet been reached among scholars of various fields such as medical sciences, religion, ethics and law on a number of generalities as well as theoretic and practical details of this issue. There have been discussions on topics such as the organ donor’s legal will, gaining consent while the donor is still alive, seeking consent from the brain dead patient’s family, nature of the required organ, observance of religious, cultural and conventional standards, individuals’ dignity and so on. The main challenge to overshadow other factors has so far been the discord among experts, physicians and religious scholars specifically, over determining the time the spirit leaves the body, and a unified definition of death. Some researchers have attempted to minimize religious, ethical and legal challenges and thus facilitate organ donation following brain death by emphasizing the urgency of organ donation and the practices related to certain specialties, and even maintain that brain death is the equivalent of death and a lifeless body. Others have focused on the time of death and the spirit leaving the body based on lexical, religious and medical evidence, regardless of equality of brain death and death, and ensuing rulings. These researchers have thus separated the solution to the problem of those in need of transplants from considering brain death to occur at the same time when the spirit leaves the body, and encourage experts to seek different solutions. Organ donation by brain dead patients is an undeniable social necessity that can be resolved without bringing about fundamental changes in lexical and jurisprudential concepts, and through other alternatives such as propounding “urgency”, declaring a patient “as good as dead” and in general “non-elucidated jurisprudential issues”. Through references to lexical, jurisprudential and medical sources and examination of previous research, the present article will review several definitions of death, spirit, and the time the spirit leaves the body, as these are concepts that are related to brain death for all practical purposes. The article also considers organ donation following brain death to be an undeniable and unavoidable fact of life in human societies, and will examine the necessity of altering lexical and jurisprudential concepts to accommodate current interests and goals.

---

With the progress of science, organ transplantation emerged as one of the modern innovations of the medical science. Like other innovations, organ transplantation brings individuals in the society some disadvantages alongside numerous advantages. Legislators have therefore adopted rules and regulations for the mutual support of society members and their rights.In this article the researchers will examine the current regulations on organ transplantation in Iran. Legal sources in Iran, especially the constitution, Islamic criminal law, health and sanitary regulations, moral codes and so on will be referred to in this respect.In the constitution (as epigraph of all laws and regulations within the country), articles 14, 29, 43, 167 will be examined, and in Islamic criminal law articles 159, 372, 495, 497 and 724 will be discussed as the most significant existing articles on organ transplantation. In relation to the moral codes and medical and sanitary regulations we studied the following: Organ transplantation act of April 5, 2000 about the deceased or patients whose brain death has been confirmed the protocol on confirmation of brain death, established 2000 executive regulations for transplant from the deceased or patients whose brain death has been confirmed, adopted May 15, 2002 act of renal transplantation and donation from living donors passed on October 20, 2008 executive regulation 13101 approved on April 29, 2006 about living donors (with the exception of transplantation from a living donor to a foreign citizen) and the charter of patient’s rights ratified in 2009. Lastly, it should be mentioned that transplantation laws and regulations that presently exist in Iran appear to be inadequate for the purpose of resolving the current challenges and problems.

---

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

---

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.

---

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.

---

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.

---

In the modern world, reproductive right is considered among the basic human rights in countries such as America and Britain. There has been growing interest in the subject and its various aspects including contraception and assisted reproductive technologies, which are giving rise to the ongoing debates. National and international legislators, governments and religions are striving to resolve the controversy among individuals and between individuals and governments and devise the perfect legislation that will cover all aspects of the subject and control all activities in this area.In the realm of bioethics and law, the issue is introduced as a right not duty, while in Christianity and Judaism it falls under the category of duty. In Islam, on the other hand, childbearing decision-making is left to the couple, which highlights the teachings of Islam regarding reproduction. In this paper, we attempted to offer a comparative study of four different points of view regarding the issue of reproductive rights

---

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.

---

In the past decades, the need for organ donation has increased while consent rate continues to remain inadequate. One of the most important limiting factors in organ donation is families’ refusal to grant consent, and therefore it is important to determine the circumstances influencing the phenomenon. The aim of this study was to investigate the factors affecting consent to organ donation in families of brain death patients in hospitals affiliated with Shahrekord University of Medical Sciences. For this purpose, a self-made questionnaire was distributed among 54 family members of brain death patients admitted in hospitals affiliated with Shahrekord University of Medical Sciences between 2003 and 2013. The data were reported as mean, frequency and percentage using the SPSS16 software. The average age of the deceased was 31.38 ± 13.72 years, and car accidents were the most frequent cause of brain death (59.3%) in this study. In addition, 72.2% of the deceased were male and 90.7% of them lived in or around the city of Shahrekord. About 37% of the families consented to organ donation. The average age of the family members who participated in the study was 42.15 ± 8.9 years. The most frequent reasons affecting families’ consent to organ donation were religious rewards (100%), confidence in the medical team and staff (100%), and confidence in physician diagnosis (100%).The findings of the study show that religion, faith and family ties affect the willingness for organ donation, and therefore specific attention should be given to these factors in educational programs. In the present study, religious beliefs and confidence in the performance of health care workers were highlighted as the most effective factors in consent to organ donation in brain dead patients' families. Consequently, in order to increase organ donation rate, special attention to these factors and proper planning is necessary.

---

According to the principle of respect for autonomy, which is one of the essential precepts of medical ethics, patients are entitled to the right of self-determination for a hypothetical future when they may lose the decision-making capacity. Thus, when still adequately competent to make decisions, a person can prepare a document and predict their therapeutic options and state their wishes for the possible time of lack of decision making capacity, or assign a surrogate who will make the best decision considering the attitudes and interests of the patient. This document, called advance directive, has advantages and disadvantages, and has been investigated from different perspectives. The present study addresses this new issue through non-systematic internet and library review of resources, and aims to investigate some aspects of this subject and examine the possibility of its naturalization from certain viewpoints, particularly from the Islamic perspective. In Islam, life is highly respected and physicians are obliged to do their best to protect human life. In cases where patients refuse the suggested treatments, even when it harms them fundamentally, the physician is obliged to respect their wishes for several reasons. Nevertheless, physicians should avoid any direct measure that may end up in the patient’s death. As regards advance directives, the patient no longer has the capacity to make decisions and has done so formerly, which may be in conflict with the physician’s responsibility to save the patient’s life under present circumstances. In such cases, despite a preliminary injunction, there is no reason to extend the patient's right to the time of their consciousness. Therefore, based on the religious principles observed in Iran, acting on the patient's previous decisions can only be valid as long as they do not conflict with the physician’s responsibilities. Furthermore, advance directives currently do not have a place in our legal system and the recognition of such documents is contingent upon further studies, including legal and cultural reviews.