Iranian Journal of Medical Ethics and History of Medicine

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The appearance and the way a doctor is dressed has a very influential effect on the physician-patient relationship. Interns and trainees of medicine must follow the principles of professional behavior as they play a crucial role during their education. The aim of this research is to analyze the interns and trainee's point of view towards dress code.
In this study, after preparing a questionnaire and assessing its validity and reliability, it was sent to 337 interns and trainees of universities of medical sciences, at Shariati, Imam Khomaini and Sina hospitals, which are selected by portion method, after ward their viewpoints were analyzed from 5 dimensions.
One hundred and seventy seven students (52.5%) and seventy students (20.8%) got mean score and high score of physical features respectively.. Two hundred and sixteen students (64.1%) and fifty four students (16%) got mean and high score of dress code respectively. One hundred and eighty eight students (55.8%) and seventy five students (22.3%) got mean and high marks in make up respectively. Two hundred and twenty three students (66.2%)were completely in favor of observing personal hygiene while one hundred and fourteen students (33.8%) just agreed with this issue. Finally, in the total physical features and dress code, 210 students (62.3%) got the average mark and 58 students (17.2%) earned high mark. Interns and trainee's viewpoints about the physical features had a significant correlation with age, sex, and educational level (P<0.05).
The results of this study shows that teaching the importance of physical feature and professional dress code is the most important action to boost the level of compliance about appearance by interns and trainees. Compiling the professional dress code can help getting this aim come true.

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Attempts to promote medical ethics principles on the national level should be consistent with the needs, expectations of the target audience, social orientations and determination of priorities. The present study was conducted through distribution of a questionnaire containing twenty medical ethics topics, and thus the priorities of instructors, researchers and policy makers regarding medical ethics were determined on a national level. Through determination of medical ethics priorities in the country, the study aimed to encourage a scientific approach to the issues and challenges faced throughout the nation based on the opinions of thinkers of this field, and to help resolve each of those issues according to national priorities. The findings revealed ten priorities in the field of medical ethics nationwide: patients’ rights, doctor-patient relationship, justice in the distribution of health care resources, autonomy and informed consent, the financial relationship between doctor and patient, hospital ethics committees, ethical considerations in public health, strengthening and capacity building in teaching medical ethics, ethical considerations in medical education, and medical research ethics.

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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.

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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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Medicine is known as a combination of science and art. Besides knowledge, a good physician should be equipped with the art of establishing communication with patients. The keystone of any efficient relationship like a therapeutic one is trust, and its deterioration makes the relationship deficient and based on mere need. Therefore, establishing an efficient relationship brings about positive results in treatment. In the last two decades, the trend in the physician-patient relationship has greatly changed, so that patient-centered care is now in focus. In this kind of relationship, physicians recognize patients as respectable human beings with their unique beliefs, attitudes, and concerns, etc. In this paper we intend to provide a brief introduction to the concept of physician-patient relationship and its chronological changes. Also, common models of physician-patient relationships (e.g. paternalistic, etc) are introduced, compared, and their most obvious strengths and weak points are analyzed. At the end, a succinct analysis on the dominant model(s) of physician-patient relationship in Iran&aposs medical settings has been provided, and the necessity of compiling a model based on Islamic values is proposed.

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Trust is a key element in the physician-patient relationship. Imam Jafar Sadiq (A.S.) stated that the proficient and trusted physician is in equal level of a just jurisprudent. Ancient ethical texts put much emphasis on physicians to be trusted. Nowadays, trust is a component of social health we believe that in the physician-patient relationship, trust has a significant impact on the practice, and increases the effectiveness of treatment and the satisfaction of patient and physician? also patient autonomy is preserved, health is positively reinforced, and patients will be more serious and less negligent with expenses, treatment, and follow up. This paper is a review/analytical article, and aims at classifying trust and examining its role in communication between physician and patient. If limited to practice, trust in the physician - patient relationship is divided into two types:

1- Unconditional trust, which means full confidence with no autonomy

2- Conditional trust, which entails maintaining autonomy.

 In the first type, where patient's autonomy is foregone, both patient and physician can be blamed. The patient is to blame due to an absence of self confidence and lack of participation in decision making and treatment, and the physician might in his place have the tendency to patronize. In this article we emphasize the importance of trust and warn against paternalism and conclude that if doctors truly comprehend the meaning of trust, they will try to avoid paternalism.

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Telling the truth to patients is a key issue in medical ethics. Today, most physicians hold that truth-telling to patients is crucial, and that lying to patients or withholding information from them is not acceptable. It seems, however, that absolute and unconditional truth-telling is not always possible, and it may not be feasible to tell some patients certain truths under some circumstances. Although truth-telling is a rudimentary principle in ethics, it is allowed to withhold truth or even to tell lies in some circumstances. From the point of view of reason and tradition, lying under certain circumstances is allowed for instance when one is disinclined to tell the truth, or in emergencies where truth-telling might lead to loss of life, property or someone's reputation, and when truth may involve two adequately unpleasant situations. In my opinion, it is necessary to tell the truth, regardless of possible harms, when continuation of treatment, or the patient's cooperation and consent depend on it, and also when the truth which needs to be told to a patient is the incurability of his disease and therefore his inevitable death,. In other cases, however, when there are truths such as severity of disease, death of others in the accident, family problems outside the hospital, predicted survival time, and other possible diagnoses, the truth can be withheld and the patient can even be lied to if there is any risk of harm to the patient.

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The most important element in physician-patient relationship is trust which has a major effect on treatment and satisfaction of both patient and physician. To be able to realize the trust between patients and physicians, at first we should find an appropriate definition of trust so in this article we study the criteria of trust and it's realization to be adapted between patient and physician.We reviewed the literatures investigating the perspective of scientists of sociology and ethics. Afterwards the issue was discussed in focus groups, and the contents were analyzed to reach to a proposed model including several criteria.We believe that trust has two sides, the trust (patients) and the trustee (physicians) and for trust fulfillment both sides should be involved. So some criteria are related to the individual patients, such as patient's needs and desire to trust. Some are related to patients and are considered as respect to patients, awareness of physicians characters, such as his/her knowledge and experiences of physician.The other two criteria are related to physician's characteristics, such as his/her commitment and appearance, and physician-patient relationship, such as communication skills of physician.

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Trust is an important factor in the relationship between physician and patient. Trust between physician and patient is an important factor in improving patient and physician satisfaction, but it will not materialize unless we define trust and its criteria. Since trust fulfillment is dependent on its criteria, in this study we tried to define these criteria. First, we explicated the meaning and concept of trust through review articles, then we proceeded to content analysis, and lastly, the logical conclusion was obtained. In this article we have expressed scientific opinions and extracted 23 components from the cited opinions. We concluded that trust can be analyzed from three perspectives: the perspective of patients with 5 criteria, the physicians' view with 2 criteria and the perspective of an observer of the physician-patient relationship with 9 criteria.

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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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Presumption of innocence is one of the fundamental principles of criminal law that has its roots in moral and religious principles. Presumption of innocence is consistent with human nature, and special attention has been paid to it in Islam. For this reason it has been included in our constitutional law as well as in the constitutions and ordinary laws of other nations, and this indicates its significance. In Shiite jurisprudence there are two major theories on the responsibility of physicians as “daman al-tabib”. Most jurists (famous) consider the physician responsible even if he or she has committed no fault. Only a minority of jurists (less-known) consider the physician to have no responsibility. Islamic criminal law believes the physician to have absolute liability, although medical practices have become more sensitive than in the past and medical incidents have increased as a result of new technology and new methods of treatment. The present study intends to adopt a new approach to rules and principles of jurisprudence, and study the necessity of using them according to the requirements of time in solving everyday problems. Moreover, the study seeks ways to prevent the regression of those rules. Therefore, it seems essential that the golden principle of presumption of innocence be applied to physicians as the manifestation of God's healing, and more attention be paid to it.

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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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Presence of physicians in different fields of the society has always been associated with ethical and legal considerations. Physician participation in legal punishment is one of the areas that are associated with different perspectives. In medical history, physicians and medical professionals have participated in legal punishment in different ways, but they have been directly involved with this process after the development of the lethal injection method. Proponents and opponents have discussed the ethical aspects of physician participation in legal punishment, and medical organizations have announced their viewpoints about this subject. In the Islamic Republic of Iran according to the Islamic punishment laws and their implementation regulations, physician participation in legal punishment is necessary, but the physician does not play a direct role in the execution of punishment. In this article we will study the main arguments of opponents and proponents as the background of the subject and will then evaluate the exact role of physicians in the execution of punishment in Iran and analyze the ethical aspects of this role.

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In order to face the challenges of today’s health system, it is extremely important to promote collaborations among disciplines. Nevertheless, it seems that nurses and physicians cooperate more effectively in academic areas, and their partnership in the actual work place and clinical settings is associated with challenges.This cross-sectional study aimed to determine the attitudes of doctors and nurses in hospitals affiliated with Shahid Beheshti University of Medical Sciences toward collaboration with each other. For this purpose, the Jefferson Scale of attitudes toward physician-nurse collaboration was used after it was translated and its validity and reliability were examined on 59 physicians and 164 nurses. Data were analyzed using the SPSS software version 18.The results showed a more positive attitude toward the concept of collaboration among nurses (3.49) than physicians (3.12) (P = 0.02). Moreover, a significant difference was observed between the attitudes of physicians and nurses toward working together across various items of the questionnaire (F = 5.06, P = 0.02), with the exception of the area of nursing autonomy (F = 0.95, P = 0.32).An appropriate nurse-physician relationship and agreement over treatment plans can increase the quality of care, and lack of cooperation can lead to stress in the workplace. Therefore, in-service training for doctors and nurses and attention to the importance of cooperation among members of the medical team must be incorporated into the nursing and medical curriculum. Thus, the traditional views on the role of nurses will change, and nurses will be able to perform their professional duties more effectively. Consequently, the cooperation between physicians and nurses and the fortified synergy between the roles will improve the quality of care.

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

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

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Medical professionalism has recently received attention in Iran, so we aimed to assess it in a single specialty educational hospital.In the present study, we evaluated observation of medical ethics principles from the viewpoints of physicians, nurses and patients. Eight principles of medical ethics were evaluated in these three groups through modified questionnaires containing 43 questions for physicians, 42 questions for nurses, and 25 questions for patients. The mean scores of those principles are as: enhancing professional efficiency (68.7 ± 23), confidentiality (67.9 ± 21), maintaining an appropriate relationship with the patients (61.7 ± 21), improving access to services (59.6 ± 21), distributing limited resources fairly (60.2 ± 25), knowledge production (61.4 ± 23), promotion of trust through management of conflicts of interests (64.8 ± 23), and perform professional responsibilities (59.6 ± 23). There were significant differences in the two parameters of “enhancing professional efficiency” and “confidentiality” between the viewpoints of the patients and the viewpoints of physicians and nurses (P < 0.0001). The difference in “maintaining an appropriate relationship with the patients”, “improving access to services”, and “distributing limited resources fairly” was significant between the viewpoints of the nurses and that of the patients and physicians. The viewpoints of the nurses and patients were significantly different only in “knowledge production”, “promotion of trust through management of conflicts of interest”, and “perform professional responsibilities” (P < 0.0001). With respect to these significant differences, the nurses’ viewpoint regarding “enhancing professional efficiency” may be more dependable due to their more accurate knowledge of the physicians’ performance and more extensive contact with them. This has also resulted in significant differences between nurses and patients or physicians in other principles as well.

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Nowadays, electronic communications technology propounds new forms of the patient-physician relationship in the field of medicine. Effective communication between the patient and the physician can play a crucial role in the process of treatment. This new form of communication greatly influences promotion of the health system by improving access to inexpensive and fast services regardless of geographic boundaries. In times of crisis, telemedicine plays an important role in delivering health services to deprived areas in a just manner. Usage of communications technology is inevitable, and due to the virtual nature of this kind of medical communication, recognition of certain ethical considerations seems essential. Successful examples of telemedicine are abundant throughout the world and usage of this technology is a helping solution for inadequacies in the healthcare system. In Iran, because of the geographical extent of the country, this technology can provide access to medical services in some cases.In order to achieve the best outcome in telemedicine, it is essential to respect confidentiality, privacy, informed consent and commitment to professionalism in this field.

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Physician-assisted suicide is an important, challenging issue in medical ethics, which the right to die is a central point in this issue. Physician-assisted suicide is offered to end intolerable pain and suffering. Although, it is a legal practice in some countries, still it is a challenging and controversial practice in ethical and legal perspectives. It has been argued that based on the principles of medical ethics, physicians should respect patient’s decision, however many ethicists and jurists believe that Physician-assisted suicide is unethical. It should be noted that the main reason for proponents and opponents is based on their interpretation about human dignity. This controversy can be resolved by reference to religious interpretation of human dignity in which asserts that Physician-assisted suicide is against human dignity and respect for human life.

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Since the beginning of the Imamia school of thought, Imamia scholars paid a great attention to issue of physicians’ responsibility. With a long-lasting debate on this issue, in most cases they have confirmed physician’s responsibility in medical error. However, in terms of a skilled medical doctor who treats the patient with no medical error but harm occurs, there is no consensus. Some scholars have said that if the physician had the patient’s (or family) consent for the treatment, then the physician is not guilty. In the contrary, some scholars believe that the physician still should bear the responsibility.This paper aims to examine the Islamic Pinal Code (no. 495) by relying on changing trajectory Imamia jurisprudence in exchange for claimed physicians’ responsibility. The legislators in Article 495 of the Islamic Penal Code (Act. 92), seems to take into account both mentioned perspectives and try to choose a middle way. However, in practice, this has caused confusion.