Iranian Journal of Medical Ethics and History of Medicine

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Background: The first experimental lobotomy was performed in psychiatric patients at 1930. At the beginning, the purpose of such experiments was the treatment of certain patients such as psychotics, sexual offenders and schizophernics, but during the years, the unpredictable results and harms appeared. Nowadays the treatment is limited to medical treatment and psychosurgery which includes two new forms of lobotomy named cingulotomy and capsulotomy. Previously physicians were performing dangerous surgery on a wide rage of patients irrespective of their consent and objections. In fact they treated them in the favor of “patients’ and public (social) interests” and some claims have risen against it. In this regard some legislators such as Canadian legislator enacted or amended their regulations and these regulations criticized.
Method: We selected the most related articles and books among the related resources. For completing this article, we searched by the keywords of Lobotomy, enforced offender to treatment, ethics.
Results & Conclusion: Studying some known cases demonstrated harmful effects of this special surgery and regarding to the ethical and legal points of view, operating patients only for the interest of patients or public, irrespective of their consent is not legitimate.

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One of the manifestations of patient autonomy in practice is gaining informed consent prior to any invasive procedure. In Iran, the process of obtaining informed consent to surgical procedures is currently limited to the patient signing a consent form that often does not offer specific information on the procedure, and patients are not given adequate time to read the form. In order to improve the present circumstances, authors of this study created information sheets specific to each class of surgical procedure, and performed an evaluation of the effectiveness of these sheets in increasing patient awareness and satisfaction. Handouts containing specialized information on various surgical procedures were distributed among 110 patients hospitalized to undergo elective surgeries in surgical wards 1, 3, 4 and 5 of Imam Khomeini Hospital Complex and surgical ward 3 of Sina Hospital the patients received the handouts prior to procedures, and were free to use the information as they wished. These patients were then interviewed through an oral questionnaire after the procedure and at the closest time possible to their discharge. At a different time, 110 other patients in similar conditions and locality were interviewed after surgical operations and as close to being discharged as possible, but without receiving information sheets. The above-mentioned questionnaire contained essay type questions regarding patients’ information about their medical conditions and the required surgical procedures, and patients were also asked about their level of satisfaction with the information they had received. The mean score for patients’ overall knowledge in the intervention group was 48.8%, and the same score was 44.6% in the control group. Distribution of specific information on the surgical procedures among the patients in the intervention group did not have a significant effect on their overall knowledge (p = 0.140), and only raised their awareness of the side effects associated with the procedures (p  0.001). Similarly, patient satisfaction levels were 60.2% in the intervention group and 56.4% in the control group, and distribution of information sheets did not affect the overall satisfaction level of patients significantly (p = 0.166), and it only increased their satisfaction with the information they had received regarding their convalescence period after surgery (p = 0.033). Since distribution of specialized information sheets like the ones used in this study generally appears to be inadequate in increasing patient awareness and satisfaction, it is recommended that in the process of obtaining informed consent, physicians dedicate enough time to educate patients on their conditions and their different aspects rather than simply present them with a consent form.

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Human cloning is one of the latest and most complicated developments in the field of medical and genetic sciences that could fulfill man’s dream of eternal life. Scientists’ achievements in this respect, however, have brought about many concerns for thinkers, particularly ethics scholars. Human and animal cloning have been examined from different angles, but one basic aspect of human cloning has received less attention from researchers and scientists, and that is the autonomy of the cloned person the reason is that gaining informed consent, which is one of the most important principles of medical ethics in human experiments, is impossible in the case of human clones. Free will lies at the core of human perfection and divine revelation, and one important issue that the present study concerns itself with is whether or not technologies such as cloning or embryonic genetic modification violate the autonomy of cloned persons. This paper attempted to look into such issues regarding human cloning through library research.

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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.

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Because of complications of medical treatments, informing patients about the rate of treatment success, potential risks, and side- effects, is considered as an indispensable part of treatment contracts. Patients' deprivation of this information can be considered as a major obstacle in obtaining informed consent. Clearly treatment without patients' or their legal guardians informed consent may lead to civil and penal liability for the physicians.
Consenting without getting enough information about the disease, and its treatment is the most important issue in this regard. Now can such consent be valid and legalize the treatment or not? In this article informed consent and the physicians duty of informing patients are compared in three legal systems of Iran, England and France and then the physicians' duty of notification will be analyzed and some suggestions for safeguarding patients rights will be offered.

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The Declaration of Helsinki, the most creditable ethical guideline for medical research on human subjects, has been updated 8 times since its establishment and the last revision was in 2008. Researchers, medical research subjects, authors, members of ethics committees, and editors of medical journals must be informed of the tenets of the Helsinki declaration in order to improve achievements of medical research and respect the rights of participants in medical research. In this study, the evolution of the Helsinki declaration is examined, and the provisions of the last version are compared with the previous version (2004). Finally, we made a practical interpretation of the last version, and discussed its differences from previous version. There are seven new paragraphs in the last version of the declaration. Four new paragraphs concern informed consent in areas of its being written and voluntary, renewed consent for using human materials, participants' right to revoke the consent, and exceptions from informed consent requirements. The other three new paragraphs focus on the research subjects' right to being informed of the declarations' provisions, vulnerable groups gaining benefit from research, and registration of randomized clinical trials. It is important for researchers to recognize international guidelines such as the Declaration of Helsinki, because it enables them to use correct scientific and ethical standards in medical research. In the last version of the Helsinki Declaration more emphasis was placed on informed consent and vulnerable groups than previous versions.

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One of the important issues in the field of medical ethics is the patient's consent to treatment. This issue has also been addressed in the law, and Islamic legislators have clarified the conditions of gaining patient's consent and approached questions such as legitimacy of treatments or surgical operations, capacity of the person giving consent and so on. In medical ethics, there are different types of consent including expressed, implied and informed consent, while the Islamic Criminal Act concerns itself only with the expression of consent and it is unclear which type of consent the legislators are referring to. The importance of this issue lies in the fact that gaining the patient's consent without meeting the specified legal conditions causes liability for the physician. This article attempts to clarify the legal conditions for gaining patient's consent and at the same time answer questions such as whether the consent mentioned in the Islamic Criminal Act includes various types in medical ethics or not, how failure to meet the legal conditions for gaining consent should be penalized, what the liabilities are in the event that the patient's consent is not gained, and other questions related to the issue

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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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Considering the importance of medicine and the ever-increasing developments in medical research, the implementation of such research according to the ethical principles and criteria of creditable national and international declarations is of great significance. According to these declarations, the researcher has the highest responsibility to observe the rights and safety of participants. The present study intends to survey the rate of observance of research ethics in proposals approved at Urmia University of Medical Sciences between the years 2003 and 2008. Three hundred and twenty four research proposals that had been approved between 2003 and 2008 were evaluated retrospectively. Related checklists (self- constructed ones and World Health Organization checklists) were completed for each project, a statistical analysis of the results was done by SPSS software, and descriptive statistics were subsequently extracted.  A summary of the most important results is as follows: In 85.5% of the proposals, the ethical considerations part was completed. In 68.4% of the cases the participants were aware of participating in the study and in 67.9% of the cases the informed consent of participants was obtained, 50.9% of which was in written form. Among clinical trials, in 80% of the proposals informed consent was obtained, 85% of which was written. Out of 60 clinical trials, 37 projects (62%) were confirmed by the ethics committee. Considering the results obtained in this study, principles of research ethics were applied more closely in this study compared to similar studies in Iran. It seems this is due to the establishment and launch of regional ethics committees in 2003 and afterwards. However, in order to bring these measures closer to current standards, holding educational workshops for honorable members of scientific boards and students is recommended. Moreover, more accurate supervision of ethics committees, especially in clinical trials and animal experimentations, seems to be beneficial.

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Refusal of medical treatment is among the most important rights of patients and a natural consequence of informed consent, although it can result in harm to patients or others and even the health care system. Treatment refusal may have various clinical manifestations whose recognition and proper understanding is essential to their management. In some cases the legal aspect is primarily dominant, such as when there is the possibility of harm to a third party. In other cases, for instance in absence of patient capacity, there are clear guidelines for decision-making. Major ethical challenges in the field of treatment refusal frequently pertain to capable patients, and this paper is mainly about the practical issues related to this group. The problems that these patients face are mostly due to improper physician-patient relationship or fleeting emotions. Caregivers should be prepared to deal with these issues and try their best to overcome obstacles and achieve patient satisfaction, with the exception of critical emergencies where treatment is carried out without consent. If all measures fail, patients’ refusal must be documented and other therapeutic interventions should be offered.

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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.

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Replacement of missing teeth with dental implants has received growing popularity in recent years. In order to select the proper treatment plan the clinician should provide a list of all applicable options. Decisions on the treatment of the edentulous area should be performed in consultation with the patient while taking into account the four principles of bioethics, that is, respect for autonomy, non-maleficence, beneficence, and justice. The dentist must inform the patient of all available treatment options and point out the advantages and disadvantages of each modality. Rendering dental services should not be based on wrong principles, so dentists’ knowledge and professional skills must be up-to-date. Informed consent is crucial, and when obtained prior to implant placement, typically will bring about better results and prevent many ethical and legal issues and conflicts. Understanding and approval are two important components of informed consent that can hasten the process of patient recovery. Moreover, patient requests and expectations should not lead to incorrect and unethical decisions on the part of the dentist. Implant dentistry may be a suitable option in replacing missing teeth, but it does not license tooth extraction in any way, as natural teeth should not be extracted in the hope of dental implants. Dental implants are not permanent, are not resistant to infection and disease, are not without risks and complications, and more importantly, require comprehensive care.

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The Declaration of Helsinki is one of the most important international documents in medical research ethics on human subjects which has been revised 7 times and the last revision was in 2013. Researchers must be informed of the principle of Helsinki declaration and the latest changes in order to respect the rights of participants in medical research. In this study, the last version of the declaration are compared with the previous version (2008). The evaluation of the changes and challenges of the final revision can be helpful in modification of the ethical codes of our country. The 2013 version included a number of important changes; it has been categorized into more clear and detailed sections. So this version has a better structure and more practical as well. The 2013 version places more emphasis on vulnerable groups and includes a separate section on the compensation and treatment of injuries due to research. The revised version of the Declaration of Helsinki also emphasizes obtaining of the informed consent (even in researches on material or data contained in biobanks) and post-trial access.

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Patients have the right to make decision about their medical care. Thus, all the available information regarding decision-making should be provided for them. In surgical context, informed consent is essential for therapeutic relationship between patient and surgeon and sustains mutual trust and shared responsibility for decision making. Thus before surgery, the surgeon should describe available treatments, benefits and harms of them to the patients. So the patient can make a correct decision. In this cross-sectional study, 200 patients underwent gynecological surgery in a hospital in Shiraz during 2014 were recruited. The questionnaire which was used in this study had three parts. The validity and reliability of the questionnaires were evaluated using expert panel and SPSS software. In this study, there was no significant association between age, marriage status, job, home place, emergency or elective surgery and the amount of informed consent. There was significant difference between patients with primary school education and patients with higher education. Patients’ participation in decision making was 57%. Patients’ information about their rights in hospital and the amount of reading informed consent form were poor. This survey shows that the amount of informed consent obtained from patients is poor. So, we should consider some changes in content and obtaining informed consent.
 

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Confidentiality in AIDS patients is one of the necessities of medical ethics, which has attracted the attention of policymakers in the health field in the last few decades because, on the one hand, it increases the trust between patients and doctors. On the other hand, it encourages them to adhere to treatment and do necessary care to patients in order to prevent the transmission of the disease to others. However, it may lead to a breach of benevolence and others’ right to health and cause problems in providing health care.  Here we discuss a practical solution for this problem through a clinical case presentation.

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One of the most important patient rights is to respect the patients’ autonomy and their participation in the process of treatment decision-making. This is of particular importance for the patients in the emergency department, who require due care in differential diagnosis leading to illness and death. However, the problem arises when this right is negligently ignored and despite the fact that it seems a simple matter, it is difficult to manage and control. Accordingly, this study aimed to investigate this issue through the case report of a patient diagnosed with acute abdomen. Moreover, an attempt was made to briefly review how negligence occurs, its causes and consequences, as well as its management strategies. In this report, the results highlighted the importance of patient participation, obtaining informed consent from the patient in the entire treatment process (diagnosis, treatment, rehabilitation, and prevention), and maintaining privacy and confidentiality regarding all medical and non-medical information of patients that are provided to the treatment staff in verbal, written, partial, and even electronic forms, especially in sensitive and stigmatizing cases. It seems that there are certain strategies to manage such negligence including timely detection, investigation of the causes and consequences, compensation for the damage, enhancing the cultural competence of the treatment staff, developing relevant local guidelines and instructions, having an efficient system with the support of the organization for handling it, and strengthening communication skills and teamwork.