Iranian Journal of Medical Ethics and History of Medicine

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Theologians describe the difference between active and passive euthanasia as in the former, we kill hopeless patients terribly suffering from an incurable disease and in the latter, and we let them die. The present research aimed at exploring for a solution to an ethical dilemma by which the difference between foundational concepts of the two types of euthanasia can be examined. Another objective of the study was to assess personal characteristics regarding this judgment. One hundred and five students were recruited, and in addition to reading the trolley problem and answering the related questions, they responded to a six-point scale self-assessment on morality and a short 20-point scale questionnaire on the five principle personality factors. Results showed that 83.8% of respondents found it immoral to kill one person in order to save 5 lives. Respondents' gender, religiousness and personality had no significant effect on their responses regarding the footbridge dilemma (P<0.05). Nonetheless, extroversion had an almost significant relationship (P=0.056, r=0.19). According to the results of the present study, the difference between "killing" and "letting die" is clear to most people, and they do not prefer killing even when there is more benefit than loss. Responses to the trolley problem were independent of personal characteristics, nonetheless, the quality of extroversion is suggested a as a potential determinant of agreement with active euthanasia.

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Moral distress is a psychological phenomenon whose effects on people’s functions can be considered as a subject of study. Although moral distress exists in numerous professions, research dedicated to this phenomenon has proved that due to the nature of the nursing profession, it is a familiar source of stress for most nurses. Nurses are more often than not faced with moral dilemmas in the workplace, and suffer moral distress as a result. The present paper aimed to study the history of moral distress, its definitions, consequences and coping strategies through library and online research, and although it attempted to investigate the phenomenon of moral distress in general, its focus has mainly been on moral distress in the nursing profession. A thorough understanding of moral distress and its negative and positive aspects is believed to raise awareness and lead to improvements in nurses, and educate them on appropriate coping strategies to help reduce their emotional suffering.

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Nurses have to cope with various forms of tension in the workplace on a daily basis. One of the factors affecting the moral distress experienced by nurses is the ethical climate prevalent in clinical environments. The present study aimed to establish the relationship between moral distress and nurses’ ethical work environment. This was a cross-sectional, correlational study on 210 nurses in select departments of medical/educational centers of the Tehran University of Medical Sciences in 2009. Data collection tools included a demographic questionnaire, Corley’s Moral Distress Scale, and Olson's Ethical Climate Questionnaire. Data analysis was performed using SPSS version 14. Findings confirmed that the nurses under study were tolerating an average amount of moral distress, although they did not perceive the frequency of morally stressful situations to be particularly high. There was no significant relationship between the moral distress of the nurses under study and their evaluation of the ethical climate of their workplace. Of the five factors affecting the ethical climate, there was a meaningful indirect relationship between managers and frequency of moral distress (P ≤ 0.04), and patients and frequency and intensity of moral distress (P = 0.001). The results obtained through this research indicated a need for authorities to pay more attention to medical/educational centers and devise various strategies in order to make work environments more ethical, so that nurses can continue to offer health care services in more relaxed environments and with less stress.

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Nurses are confronted with numerous situations calling for moral decision-making in their workplace every day. Nursing students should therefore attain a satisfactory level of moral development during their university years. The present study was conducted to determine nursing students’ level of moral development, as there seems to be a shortage of similar studies throughout the country. This descriptive, correlational research was performed in 2010 study samples were 115 junior and senior students of the Department of Nursing and Midwifery of Tabriz University of Medical University who were selected by census. These students’ level of moral development was evaluated through the Nursing Dilemma Test (NDT), which has been created based on Kohlberg’s theory of ethical development. NDT assesses nurses’ moral development in three levels: pre-conventional, conventional and post-conventional, and evaluates their observance of clinical considerations at the same time. A number of the participants’ sociodemographic characteristics were also collected through a questionnaire. Data analysis was performed using SPSS statistical software, and descriptive and inferential statistics. According to the findings of this study, 13 students (11.3%) were in the pre-conventional, 33 (28.7%) in the conventional, and 55 (47.8%) in the post-conventional level, and 14 (12.1%) took clinical considerations into account more than others. There seemed to be no meaningful statistical relationship between the students’ moral development and their age (P = 0.49), sex (P = 0.21), marital status (P = 0.79), place of education (P = 0.32), and year of education (P = 0.92). These results showed that although approximately half of the students under study were in the post-conventional level, which is an acceptable level of moral development, a great percentage were still in the lower levels. This means that those in administrative positions in nursing departments need to pay more attention to the moral education of nursing students.

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In this paper, different definitions of moral conflict and moral dilemma at two levels of recognition and observing moral duties are taken into consideration and some instances of usage of conflict in physiology (conflict of stimulant and goals) and sociology(conflict of roles and norms)are mentioned. Also concepts and constraints used in the moral dilemma, especially the concept of "ought to" and the concept of "Inescapable of wrongdoing" are surveyed in a logical analysis. If in definition of moral dilemma, the concept of “ought to” and “duties” being transformable to “commensurable reasons” and their justificatory values, many of apparent moral dilemmas will be solvable and only if the values contained in the duties, being incommensurable and non-infringement, moral wrongdoing will be inevitable. In this research, it will become clear that why and how proponents of the possibility of moral dilemmas under pressure of logical argument against the possibility of moral dilemmas and criticisms of opponents, in order to provide the necessary features for a genuine dilemma have suggested variety and supplementary definitions of moral dilemmas such as: natural, disjunctive, two shape and prohibition definitions. Natural definition of moral dilemma represents a situation in which the agent sees himself as both a moral duty, while he can't do it well. In disjunctive definition agent is required to perform either task. In two shape definition (consisting of the "ought to" and "ought not to"), on the one hand the agent ought to do and on the other hand ought not to do the same. In prohibition definition, the agent should not perform any of the two while he has no choice but to do one.

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Narrative ethics is an approach that is well known for ethical education and moral development.  In narrative ethics, by using a story, its components and characters, ethical knowledge and awareness can be achieved. This approach is very useful in medical ethics education and is helpful in dealing with ethical dilemmas. In fact, part of ethical development, in addition to moral judgment, is to reinforce the ethical sensitivity in which narrative ethics can play a significant role for this purpose.This approach has been widely used for teaching morality in Persian literature and history telling, such as Mathnavi. Narrative ethics can be applied by telling stories about patients' life and their experience of illness. It can also be used to criticize and analyze the clinical situation and explore ethical challenges that healthcare providers face in their daily practice. Thus, it can help to prevent ethical conflicts by establishing interaction between ethical principles and patients' values. This paper emphasizes the application of this method in medical ethics education and ethical decision-making.    

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Moral intelligence is the capacity of understanding right from wrong, choosing what's right and then behaving morally. This research was aimed to determine the moral intelligence status of the faculty and staff of the Shahid Sadoughi University of Medical Sciences.This descriptive/analytical research was done through cross-sectional method in 2011. Research population was comprised of the faculty and staff of public health and paramedical schools of Shahid Sadoughi University of Medical Sciences. Sample size was 100 people who were obtained by using stratified-random sampling method. Required data was gathered by a Lennick and Kiel valid questionnaire. Data analysis was done through the SPSS16 software.Research findings indicated that both faculty and staff have "very good" status in integrity, forgiveness and responsibility. Also, faculty members and staff have "very good" and "good" status in compassion respectively. The status of moral intelligence in faculty members and staff is "very good". There is a statistical meaningful relationship between age and moral intelligence status (P=0.04) but there is no relationship between other demographic variables and emotional intelligence.Moral intelligence status of faculty and staff can help the university to conduct its role in moral development of students effectively.

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Moral distress is one of ICU nurses' major problems that can happen due to various reasons and may have several consequences. Considering that certain variables can be related to moral distress and turnover intention in nurses, this study was done to determine the correlation between ICU nurses' demographic characteristics and their moral distress and turnover. In this correlational study, 159 ICU nurses were selected from medical universities of Iran. Data collection instruments included a demographic questionnaire, ICU nurses' moral distress scale, and Hinshaw and Atwood's turnover scale. Data analysis was done by using SPSS 17_. The findings showed high level of moral distress and turnover in ICU nurses. The results revealed a positive statistical correlation among ICU nurses' age, their work experience, the ratio of nurses to ICU beds and their moral distress. However, there was no correlation among sex, marital status, educational degree, work shift and moral distress. Similarly, moral distress and intent to turnover did not have a statistical correlation.The results showed that increasing recruitment of young nurses and nursing staff, and diminishing ICU nurses' moral distress and turnover intention are essential.

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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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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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Moral distress is one of the common issues in nursing that has been receiving a lot of attention in research related to this profession. Moral distress is a phenomenon that can impact nurses, patients and health systems greatly. One significant impact of moral distress on nurses is its role on their desire to continue to work in their profession, and the present cross-sectional, descriptive and analytical study was conducted in order to determine this impact. Study samples were nurses in Birjand teaching hospitals who were selected through polls and according to entrance criteria. A 22-item questionnaire was developed by combining demographic information, Corley’s moral distress scale and the nurses’ desire to stay in the profession. The questionnaire was translated from English by the researcher and its validity and reliability were assessed. The results indicated that there is no significant relationship between moral distress and the desire to stay in the nursing profession (P>0/05). Moreover, levels of moral distress in the nurses in this study were moderate 2.25±0.6 (mean±SD) Given the level of moral distress in nurses and its possible consequences, strategies and solutions should be devised to familiarize nurses with moral distress and its underlying factors in order to reduce the undesirable outcomes of this phenomenon more effectively.

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One of the most important issues in nursing ethics is moral distress, which is a severe psychological problem among nurses. The purpose of this study was to determine the nurses’ moral distress in the hospitals of the northwest of Iran.This was a cross-sectional study in which 418 nurses were selected by randomized multistep sampling method in the northwest of Iran in 2012. Data collection was done using the moral distress standard scale with high reliability and validity. In order to analyze data, descriptive (mean, standard deviation, frequency and percent) and inferential statistics (independent t-test and one way ANOVA) were used.The mean score of nurses’ moral distress was 148.49 ± 32.93, and 222 nurses (53%) suffered from severe moral distress. Of the three provinces under study, Zanjan (152.46 ± 35.88) and intensive care units (152.72 ± 33.36) had the highest moral distress scores. Among the respondents’ demographic characteristics, province (P < 0.01), education (P < 0.05), type of shift (P < 0.05) and job status (P < 0.05) were significantly related to the level of moral distress experienced by the nurses.Due to the high level of moral distress in the nursing profession, dealing with it requires a lot of attention. Studies on casual and predictive factors in different wards and teaching coping strategies to nurses appear to be necessary in order to address this issue.

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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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Moral distress is an important issue in the field of medical ethics that can have serious effects on nurses, patients and health organizations. One of the most common effects of this phenomenon is professional stress in nurses. Stressful situations in nurses’ job environment lead to burnout and dissatisfaction, and adversely affect the quality of care.This was a cross-sectional study aimed to determine the relationship between moral distress and professional stress in 220 nurses of educational hospitals in the city of Birjand. Data were collected using a 51-item questionnaire based on Corley’s Moral Distress Scale and Wolfgang’s Health Professions Stress Inventory. Reliability and validity of the questionnaire were assessed by the researchers, and its reliability was calculated using Cronbach’s alpha (93%).The results indicated a positive relationship between moral distress and professional stress (P<0/05, r = 0/8). Intensity and frequency of moral distress and professional stress were reported average.Moral distress and professional stress were reported at a frequency and severity of moderate size. Findings of this study can provide guidelines for educating nurses on this phenomenon and the conditions leading to it. They may also be used to develop management strategies and establish organizations to prevent and minimize the consequences of these phenomena in nurses.

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Due to the development of societies and nursing sciences, complexity of the ethical situations that nurses encounter is increasing. Moral sensitivity is the first component of ethical behavior, but most of the nurses encounter many barriers in acquiring it. This study was an attempt to determine barriers to ethical sensitivity in nurses’ viewpoints in educational hospitals of Sabzevar in 2012.This descriptive cross-sectional study was conducted on a random sample of nurses working in hospitals affiliated to Sabzevar University of Medical Sciences, Iran (n = 125). Data were gathered through a questionnaire developed by the researchers containing 30 items in four categories of ethical sensitivity barriers including “managerial”, “environmental”, ”patient related” and “nurse related”. Validity and reliability of the questionnaire were assessed = α) 0.85), and data were analyzed by SPSS version 16.The most important barriers were “insufficient number of staff” (83.2%) in the management area, “inappropriate and intensive working shifts” (78.4%) in the nurse related category, “lack of awareness of nurses’ duties among patients” (84.8%), in the patient related category and “overcrowded wards” (76.8%) in the environmental area. The results of this study emphasize the importance of moral sensitivity barriers in all four areas of management barriers, environmental barriers, and barriers to nurses and patients, and could be of special interest to managers and health planners.

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

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This study aims to develop a national questionnaire that measures the moral sensitivity of Iranian medical students. The questions were developed based on ethical vignettes in educational documents, the professional code of conduct in Tehran University of Medical Sciences and medical students’ workbooks in ethics course. A pilot study was conducted to evaluate the clarity and appropriateness of 7 primary questions. Next, 38 questions were reviewed for content and face validity by an expert panel including 7 expert teachers and 4 lay experts (medical students). In order to assess the reliability of the finalized 35 questions, a test-retest was conducted on 30 medical students with a 2 weeks interval. Through test-retest study, the median values of intraclass correlation coefficient (ICC), Spearman and Kappa were calculated at 0.81, 0.65 and 0.53 respectively. The final version of this instrument consists of 24 scenarios, each presenting an ethical challenge, and has a Cronbach’s alpha reliability score of 0.67. The final questionnaire could be used as a valid and reliable research instrument to determine the moral sensitivity level of Iranian medical students. Another application for this instrument may be evaluation of the effectiveness of curricular reforms by longitudinal studies. To the best of our knowledge, this is the first context-specific instrument on moral sensitivity assessment in Iranian medical schools.

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