Iranian Journal of Medical Ethics and History of Medicine

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Throughout history, various religions and schools of philosophy have viewed human dignity as an important issue and a topic of discussion. The theoretical roots of this concept lies in ancient philosophies and religions, in Medieval as well as Modern periods, the most significant of which may be the Cyrus Cylinder, Stoicism, teachings of philosophers of the Renaissance period and of thinkers such as Immanuel Kant and John Locke, the Universal Declaration of Human Rights, and Abrahamic religions. Human dignity is infallibly referred to as being intrinsic and inviolable, and although there is no one comprehensive, inclusive and universally accepted definition for the term, it is fundamentally the characteristic that lies at the core of the basic rights of humans. In biomedical ethics there are two different dimensions to human dignity: the dignity of the individual and the dignity of humanity as such, and while the former is considered to be absolute, the latter is relative, as it is realized simply by belonging to the human race. Human dignity applies to all the principles of biomedical ethics, and sets the standards for all manners of reasoning and inference in this field. In areas such as research ethics, ethics of beginning of life and end of life care, and public health ethics, human dignity has clear requirements and implications, for instance regarding issues such as unethical uses of the embryo, fetus, and the human body for commercial purposes, the right to live and die with dignity near the end of life, and the right to basic indiscriminate health care.

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Caring for dying patient is one of the painful events and a tough experience for nurses. Care of dying patient according to his/her cultural norms is one of the principles of nurse's professionalism. Therefore identifying and explaining the daily experiences of nurses in cultural care of dying patients would help in determining caring standards. Due to the lack of such studies, the aim of this study was to explain the nurses' experiences in the care of dying patients.
This study is a qualitative investigation with content analysis method. Eighteen nurses working in teaching hospitals of Tehran were selected by purposeful sampling method from 2010 to 2011. Data were collected through semi-structured face to face interviews. Content of the interviews were transcribed and analyzed by content analysis.  
The findings were classified into two themes of cultural exposure and cultural skills.  Understanding of family presence and family bereavement were two sub-themes of cultural exposure.  Cultural skills consist of 3 sub-themes i.e., preparation for telling bad news, facilitating facing death and solacing family members. 
Regarding our results, in order to meet patients and their families expectations in a respectful manner, nurses awareness of cultural norms of the dying patient and his/her family seems to be necessary. It would be an important step in reforming and improving nursing performance and professional development.

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In spite of increasing advances in technology, medical equipments, costs, geriatric population, consideration to ethical and legal issues has increased in nursing profession. This study aimed to explore ethical codes and consideration of ethical issues and severity of ethical distress experienced by nurses at intensive care units. A cross-sectional survey using questionnaire was conducted by a census of nurses in intensive care units in educational and treatment centers of Hamadan. Nurses value most the ethical codes related to responsibility (95.1%), accountability (95.1%), patient support (77.3%), secret keeping (83.4%), and honesty (78.5%). They studied patient rights statement 2.47 times with standard deviation of 2.86. Only 50.3 percent of nurses had education about professional ethics. Nurses had mean of mark in severity of ethical distress 99.34 ±46.61. Severity of ethical distress was moderate in nurses. There was not significant relationship between demographic data and severity of ethical distress. There are more needs to assess for effects and effective factors on ethical distress in intensive care units nurses.

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Spiritual care includes assistance in performing religious rituals to support those seeking connection to the spiritual world. It forms an essential part of holistic care and helps finding answers to issues concerning life, pain, and death. This study was conducted to understand cancer patients' perception of spiritual care.A qualitative content analysis approach was applied to conduct the study. Semi-structured interviews were undertaken with convenience sampling of 17 cancer patients and their family members in oncology wards of a hospital in Tehran and Behnam Daheshpor Charity Organization. The recorded interviews were transcribed verbatim. For data reduction, data were labeled and coded before content analysis.The following themes were identified: characteristics and duties of nurses with a spiritual approach in religious and non religious domains, care with a spiritual approach in religious and non religious domains (emotional, communicational, functional), barriers to spiritual care.According to our findings, nurses do not satisfy all spiritual needs of the participants, because the characteristics and practices of nurses do not meet the expectations of patients and their family members, and ward environment does not support such care.

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Valuing human being is the foundation of nursing and the essence of care. Specified aspects of the health care are not compatible with the humanistic agenda. Thus, the challenge is to integrate a humanistic approach into nursing. Nursing scientists have tried to solve this problem by developing human centered theories. Internal evaluation of these theories helps decide about their applicability in solving this problem and enhancing a humanistic approach.The aim of this article is to investigate the applicability of some humanistic theories to nurses' practice. The method is critical review of related literature. Data have been gathered by consulting books, searching some data bases, and using some guiding questions. Findings revealed that humanistic nursing theories, transpersonal care, and human development are becoming specifically expanded under the influence of humanism philosophy. In these theories, human being is free and prepared to grow in a mutual interaction with the environment. Nursing flows from its presence along side others and respect for people's potentials, and has a share in human growth. Emphasis on human interactions has increased the scope of applicability for these theories, but some characteristics of these theories, users, and different context necessitate modifying these theories and developing new ones.      

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Nurses play an important role in end-of-life care for dying patients. Based on the essence of the work environment, nurses are confronted with dying patients and their requests for euthanasia more than other care givers. However, little is known about their attitudes towards euthanasia. Hence, aim of present study was to determine nurses' attitudes toward euthanasia. In this descriptive-analytical study, 91 nurses who employed in intensive care units situated in educational and medical hospitals affiliated to Guilan University of Medical Sciences participated. Nurses attitudes evaluated by using Euthanasia Attitude Scale. Data analyzed by descriptive and inferential statistics (T-test, ANOVA and generalized linear models) by SPSS software version 16. Majority of nurses (83.5%) had negative attitude toward euthanasia. Univariate analysis showed no significant statistical relationship between demographic factors and nurses' attitude toward euthanasia, whilst age (P < 0.029) and employment status (P < 0.004) were related to nurses' attitude toward euthanasia in regression analysis.     
Findings of the present study showed that majority of nurse's believe in care of dying patients for health maintenance and life continuance even in the end stage of life. They don't accept euthanasia at any condition. Perhaps, more accurate studies need to assess other confounding factors such as nurses' knowledge, practice and role.

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By the late 1960s, there seems to be a growing number of articles in medical journals on the subject of the distress that many terminally ill patients declared they had gone through due to repeated resuscitations that only prolonged their suffering. This demonstrates that standard protocols of resuscitating any patient who is undergoing a cardiopulmonary arrest may bring about new problems. A review of studies shows that dealing with patients who are in the last days or hours of their life has been a major challenge for healthcare professionals, and making decisions on therapeutic approach is one of the most fundamental skills for healthcare staff. The scientific, ethical, religious and legal dilemmas in this field make decision-making difficult in some cases. In this paper, we reviewed articles published during the past 30 years, through which the views of health care providers including physicians and nurses on the issue of do not resuscitate (DNR) orders in different societies had been studied. The Islamic perspectives have also been discussed in brief. Moreover, DNR guidelines prepared by various countries such as America, Britain and Saudi Arabia have been assessed. For searching the related studies, we used authentic electronic databases and many reliable websites. Some articles were obtained through hand searching of the references of searched articles.The results showed that despite substantial studies, caring teams are still facing the challenge of DNR in different societies. In Iran, considering the religious values and beliefs, the matter needs more deliberation to help the caring teams to deal with the clinical issues. The religious and cultural background call for a national guideline to be adopted based on Iranian-Islamic culture. Education and awareness rising of different groups including patients, general public, healthcare staff, and health policy makers is crucial in all countries all over the world, and particularly in Iran.

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Moral distress is considered as an important issue in nursing. Nurses participation in ethical decision making and taking deliberate action are facing them with many ethical challenges in their work environment. Confronting those challenges can lead to moral distress. This descriptive study was conducted to determine moral distress and its contributing factors from the perspective of oncology nurses in Tehran teaching hospitals in 2011. Data collection was done through a demographic questionnaire, the Moral Distress Scale – revised (MDS-R) and a questionnaire on moral distress related factors administered to all oncology nurses with inclusion criteria. Findings showed that nurses reported a high level of moral distress overall. The highest level of moral distress was associated with giving inadequate information to patients about informed consent and carrying out a physicians’ order for unnecessary tests and treatments. A significant correlation was found between oncology nurses’ age, their work experience and employment status with moral distress. Institutional factors such as managers’ support, nurses’ autonomy and having determined duties had the greatest effect on moral distress from oncology nurses’ view. Oncology nurses commonly encounter situations that are associated with high levels of moral distress, and therefore strategies need to be developed in order to mitigate moral distress.

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When medical treatment is futile, the physicians must refrain from treating patients, and this can lead to serious and stressful problems. In this paper, in order to facilitate ethical decision making relevant literatures have been reviewed. This review article aimed to explaining the different clinical forms of futile treatment, and exploring theoretical and practical dimensions of futility. The first problem in this field is ambiguity in the definition of futility. The next problem is determining the practical criteria and attributing the meaning of futility to particular treatments. This ambiguity is partly due to different perspectives about the goal of treatment, and variations in physicians' and patients’ values and also disagreements regarding the person who should have the right to make decisions ultimately. It may also be related to finances and immoral motives. The third problem is some practical conflicts the most notable are futile care, requested by the patient and the sanctity of life, especially in the concern of religious considerations. In this regard, several definitions have been proposed for the futile treatment. Studies indicate that requesting futile care is often due to emotional problems or lack of trust a case that requires the physician’s tact to resolve and rarely is resolved by rule. Another serious problem that is regarding to end of life cares, especially in the context of religious views, is the necessity of life saving, that is closely related to the inactive euthanasia. This can be solved by giving priority to more important issues such as health budget constraints.

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Nurses encounter challenging ethical issues in practice that can make decision making tough for them. The purpose of this study was to determine the moral sensitivity of critical care nurses in clinical decision making and its correlation with their caring behavior in teaching hospitals of Bandar Abbas in 2012.This research is a descriptive analytic study with intensive care unit nurses as its participants. A demographic and background questionnaire, a standard questionnaire of the nurses’ moral sensitivity, and a caring behavior questionnaire were used to collect information. Data were analyzed using SPSS16 software, descriptive statistics, Mann-Whitney U test, Kruskal-Wallis, and Spearman’s correlation.The mean score of the nurses’ moral sensitivity was 70.15 ± 6.90 (maximum score was 96 and minimum score was 49) that was moderate in 85.6% of the nurses. The mean score of the nurses’ caring behavior was 108.90 ± 10.62 (maximum score was 120 and minimum score was 69). There was no significant correlation between moral sensitivity and caring behavior scores, but both scores were significantly associated with the place where the nurses were working. The dimension of respect for patient autonomy had a significant relationship with participation in medical ethics seminars or workshops.The moral sensitivity of the nurses in this study was moderate and did not have a significant correlation with caring behavior scores. In view of the fact that nurses deal with serious situations in patient care that call for adequate ethical abilities for decision-making as well as good performance, it is necessary for them to be familiar with and sensitive to ethical issues related to their profession.

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Justice is one of the main principles of ethics in the healthcare system, and its establishment at macro level depends on formulation of appropriate policies by policy-makers and healthcare providers. Health care policies and payment and reimbursement systems have a significant impact on health systems’ efficiency and cost control. In this paper, payment and reimbursement policies and their impact on financial incentives will be reviewed moreover, financial policies in the national health care in Iran and related challenges will be mentioned in brief. There is no doubt that none of the payment and reimbursement policies is perfect and each of them has the potential to put caregivers or health care providers financially at risk. Therefore, policy-makers should select a combination of the best approaches, considering socioeconomic factors, in order to provide a maximum coverage of health services and ensure fairness in the health system. Efficient payment and reimbursement approaches should undoubtedly preserve the rights of all parties in a fair and logical manner. Current national policy shows that a high percent of health care expenditures are financed through out-of-pocket payments, and therefore appropriate policies should be adopted to lighten this burden. Considering the accelerated trend toward the Family Doctor Plan in big cities in Iran, the present paper would be helpful for many health care providers, physicians and other health care professionals.

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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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Moral intelligence is one of the dimensions of intelligence that can provide a framework for the proper function of man, and be used as a predictor for people’s conduct. Nurses’ performance is of great importance because of the moral and human nature of their profession, and their adherence to ethical principles improves the nursing care quality as well as organizational performance. Therefore, the present study aimed to assess moral intelligence in nurses.This cross-sectional study was conducted on 400 nurses from teaching hospitals in South Khorasan. Participants were selected through census method. Data were collected by Lennik & Kiel’s moral intelligence questionnaire, and data analysis was performed using SPSS 16 software and descriptive and analytical statistics tests. The results suggest that the nurses’ moral intelligence score was 4.35 ± 0.56 (range: 1-5). There was a direct and meaningful relationship between moral intelligence and age and years of practice (P < 0.05).Optimal levels of moral intelligence suggest the importance that nurses attribute to moral values, and can also be an indirect manifestation of their moral conduct in healthcare environments.

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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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Moral distress is one of the ethical challenges that nurses face due to the nature of their career. Nurses' frequent confrontation with this phenomenon can have different outcomes such as frustration and boredom in providing patient care. This will lead directly to a decline in care quality and can hamper the accomplishment of health goals. Therefore, the present study examined the relationship between moral distress and compassion fatigue in nurses.This cross-sectional study was conducted on 260 nurses of intensive care units in Kerman who were selected through convenience sampling method. In this study, Corley’s moral distress scale and Figley’s Compassion Fatigue Scale were used for data collection. The collected data were analyzed using the SPSS software and descriptive and analytical statistics.The results of this study indicate that there is a significantly positive relationship between moral distress and compassion fatigue (P<0.05). From a total range of 0 to 5, the average score of moral distress was 3.5±0.8 in terms of intensity, and 3.9±0.55 in terms of frequency. The mean of compassion fatigue score was 3.5±0.68 from a range of 0 to 5.Moral distress and its association with compassion fatigue suggest that conditions contributing to moral distress can have an important role in the quality of care. It is clear that strategies should be adopted to prevent the occurrence of these conditions. Informing nurses about moral distress and its consequences as well as periodic consultations will play an important part in the identification and management of moral distress and its consequences.

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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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Patient autonomy is the opposite of paternalism and an essential element in individualised, patient-centred, ethical care. Challenges associated with patient autonomy are culture-related and have not been fully investigated in Iran so far. The aim of this study was to explore the challenges to the autonomy of patients in Iranian hospitals.This was a qualitative study using conventional content analysis methods. In 2013 13 patients, 7 nurses and 1 doctor were selected from three Tabriz and Hamadan teaching hospitals using purposive sampling to participate in semi-structured interviews. The interviews were subjected to qualitative content analysis and analysed using the MAXQD10 software.Fifteen categories and three themes were identified. The three main themes related to challenges associated with patient autonomy were: interpersonal factors, altered relationships, and organisational constraints. In summary, this study revealed some challenges associated with patient autonomy that the treatment team, managers and planners in the health care system should target in order to improve patient autonomy.

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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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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.

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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.